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Marrakesh Declaration on access to health care for the poorest – our commitment

9/27/2012

4 Commentaires

 
From 24th to 27th September 2012 , the Financial Access to Health Services Community of Practice co-organized, with Ministry of Health of Morocco and JLN, a workshop entitled "Equity in Universal Health Coverage: How to reach the poorest" in Marrakesh, Morocco. The workshop gathered policy makers, scheme managers, agency representatives, scholars and members of parliament. At the end of the workshop, a declaration was issued. The declaration engages participants, not the agencies or governments they work for. It marks their personal commitment to work for better access to health services for the poorest in Africa. You also can adhere to the Declaration on our facebook page. Join the movement and make your own personal commitment, even the most modest one.


We, as participants of the workshop on “Equity in UHC: How to reach the poorest”,
We as members of the communities of practice affiliated to “Harmonization for Health in Africa”,
We as experts involved in health systems in Africa,

Are conscious of the deep inequalities in terms of access to health care in our countries,
Are conscious of the impact of these inequalities on the health of the poorest,
Are conscious that access to health care for the poorest is dependent on our health systems,
Are conscious that assisting the indigents, the excluded, the poorest of the poor is inscribed in our shared human dignity.

We are enthusiastic about the growing interest of the African States and their partners in their efforts to improve universal health coverage.
We consider essential that this interest be translated as rapidly as possible into actions and concrete measures in order to benefit the poorest.

Consequently, we commit to taking action personally:
By supporting the implementation of strategies to improve access to health care for the poor.
By building on and accompanying the mechanisms to extend universal health coverage.
Finally, by continuing to focus all our energy on facilitating equitable access to health care in our countries.

Issued in Marrakesh, Morocco, September 27th 2012.
4 Commentaires

An online debate on "Performance-based financing in low- and middle-income countries: still more questions than answers"

9/24/2012

3 Commentaires

 
One of the two editorials of the August issue of the WHO Bulletin was dedicated to Performance-Based Financing (PBF). Fretheim et al. reported the main findings of their Cochrane review published a few months earlier. In the weeks that followed – despite many experts being on holidays and the summer “torpor” – a discussion developed on the online discussion forum of the PBF Community of Practice (CoP). The discussion benefited from contributions by two authors of the review (Atle Fretheim and Sophie Witter). This blog post summarizes the main points of the discussion. It tries to be as objective as possible; you can access the whole exchange of emails on the Resources page of this blog.

Collection, editing, titling and introduction: Bruno Meessen, September 12th 2012.

Launch of the debate

On August 9th, Emmanuel Ngabire (School of Public Health, Kigali), co-facilitator of the CoP, shared the article on the Google group. The first response came two hours later, from Stefaan Van Bastelaere (Belgium Technical Cooperation, Brussels). He expressed his concern on the possible impact of the editorial and his frustration: “The authors reduce PBF to a strategy that generates ‘quantities’, which in my opinion is unfair.”   

Bruno Meessen (Institute of Tropical Medicine, Antwerp), lead facilitator of the CoP, then invited members of the discussion group to read the paper and share their views.

Longin Gashubije (Ministry of Health of Burundi, Bujumbura) questioned the narrow definition of PBF used by Fretheim et al. in the editorial: “I think PBF is more than the transfer of money; when well implemented, it allows to transform the whole health system”. He also explained why no randomized study was done in Burundi: the mere observation, through the monitoring system, of improvement of quantitative and qualitative indicators (that had never improved before the implementation of the PBF) turned out to be sufficient to persuade decision-makers to scale up the pilot experience. 

Authors of the review are willing to engage in dialogue

On August 10th, Atle Fretheim (Norwegian Knowledge Center for the Health Services, Oslo) joined the group. After introducing himself, he recommended members of the discussion group to read the Cochrane review as well, not only the editorial. He expressed his willingness to engage in a dialogue on how PBF schemes might be evaluated in a practical and feasible, but robust way.

On the same day, Bruno Meessen reacted. The accumulated frustration was palpable – much of his long mail concerns the researchers’ lack of interest (so far) in setting up a real dialogue with PBF implementers. As far as the systematic review is concerned, a better connection with the field and the implementers would have prevented some misunderstandings. 

Start of a discussion on the Cochrane review technique applied to health system reforms and interventions

In the same mail, Bruno also shared his personal view (as a researcher) on the limits of systematic reviews. However, he acknowledged that the discussion will be beneficial to strengthening the impact evaluation program on PBF.

Still on the 10th of August, Sophie Witter (University of Aberdeen), first author of the Cochrane Review, answered Bruno.  “As a health systems person, I can fully understand your frustrations with the Cochrane process. It has its strengths and limitations, like all methods.”  In her mail, she reminded where systematic reviews fit in the body of knowledge. She acknowledged that “it may be a bit early for the evidence on PBF, but these reviews are updated periodically, so that should not be a problem in the longer term” and that “PBF is a particularly tricky topic for systematic reviews as it has been interpreted and implemented in very different ways and very different contexts. She added that “these are all issues we highlight in the review. We call for more research on systemic effects and the relationship to different contexts.” 

On August 11th, Por Ir (National Institute of Public Health, Cambodia ) – who just finalized a (non-systematic) review of evidence on RBF in maternal and neonatal health on behalf of the German Development Cooperation – shared his surprise “to see many reactions to this editorial, but not to the Cochrane review itself when it was published. Por did read the Cochrane review, and found it “well written with very transparent Cochrane recommended methods and well balanced findings and conclusions. So, if we want to challenge the findings, we better challenge the Cochrane review methods (mainly for health system research), but not the authors.”

A Cochrane review too keen on including enough studies?

The debate quieted for nearly a week, but was then re-launched by Joanne Harnmeijer (ETC Crystal, Netherlands) on August 17th. She came back on one of the points raised by Bruno, his assessment that the Cochrane review came too early. The discussion which followed provided the CoP members with some insight into the tensions internal to the systematic review. To Joanne, the review was unfair: the reviewers included data, reports or studies which did not necessarily pursue Cochrane standards and then in the next step of the assessment process, they correctly gave these studies a very low score of rigor.

On the same day, Sophie Witter reacted, providing more information on the approach taken and how it complied with Cochrane standards. Joanne responded still on the same day, reiterating her point. She emphasized Atle’s recommendation to have “a debate on how PBF-schemes might be evaluated – in a practical and feasible, but robust way” – is an important one.  Her own contributions fit in this agenda.

Joanne’s mail also triggered a response by Atle. He commented on the selection criteria. He reminded us of a few Cochrane rules that need to be respected if the review concerns a health systems intervention. He also wrote: “We do not criticize authors of the original studies. It is not our intention, anyway. On the contrary! They may have conducted the best study possible given the circumstances. I  would like to add that we are very thankful to many of the original authors. Several of them responded promptly to our e-mails and even sent us their full datasets. I think Cochrane reviewers in general struggle much more than we did when trying to engage study authors and getting access to unpublished data. So, we are very thankful, indeed!”

Still on the same day, Joanne answered Atle. The disagreement remains.

How to deal with the contextual factors in the assessment of PBF schemes? 

On August 21st, Eric Bigirimana (AEDES and BREGMANS Consulting, Cameroon)  came back on the importance of the context for the design and effectiveness of PBF schemes. He illustrated that with incisive observations made by participants of a study tour in three African Great Lakes countries. Eric is also a researcher. He reckoned an alternative research approach – the realist evaluation one – would take contextual factors better into account. In his long mail, he argued why.

Sophie, who is very familiar with the realist evaluation approach (she is currently the lead coordinator of a research project on selective free maternal health care which partly relies on this approach), responded:

“I think that the realist evaluation approach is very interesting and agree that it would be well applied to PBF. For the Cochrane methods, if there are enough robust studies, then you can look for context patterns. Unfortunately, if you only have a few (as was the case for the PBF review), then that is ruled out. But I would just note that the methodology in itself is not unable to take into account contextual differences.”

Contribution by Robert Soeters: a synthesis, some other criticisms and a way forward in terms of research

On August 22nd, Robert Soeters (SINA Health, Netherlands) sent his contribution. In his long mail, Robert provided some background on how he had been involved in the systematic review process. He felt that his commitment to transparency had not been rewarded by a similar commitment on the side of the reviewers. If field workers had been given the opportunity to give early feedback on the findings of the review, that would have been a valuable validation process for him. Robert also explained how current PBF knowledge has developed gradually over time through accumulation of experience and hinted that adoption of PBF best practices is another kind of validation process, one in terms of relevance. His assessment of the review was that “the result is a biased set of recommendations and some conclusions, which are communicated out of context.” He then developed this point by providing some more information on a few countries he has been working in over the past years. 

In the rest of his mail, Robert put forward a few ideas for a different approach on how to conduct PBF research. He raised different concerns, which matter for this future agenda. One is to find research strategies which do not harm the policy process, for instance randomization across districts (and not within) and gradual roll out of PBF “whereby at first a number of districts are included in the PBF intervention and  control districts that are not (yet) included in PBF.”

As for systematic reviews, he insisted on focusing on homogenous interventions. “ There is a quickly growing consensus in low- and mid –income countries on the definition of PBF and it should be avoided that studies are included of projects that do not qualify as PBF. It is unhelpful to study a project that is not PBF and then draw conclusions as if it is PBF. Cases in point were studies on Uganda (Palmer et al) and Zambia (Cochrane Review).” Similarly to others, he stressed the importance of context.

He concluded by endorsing the common objective of working on research methodologies. “We invite the academic world to constructively engage on the PBF health reforms and thereby to improve the research agenda.”

A rebuttal letter by Atle and a shared commitment to a strong research program on PBF

On the same day, Atle responded to Robert, point by point. However, for an unknown reason, the mail never reached the Google group. In his email, Atle reminded CoP members of some of the rules of a Cochrane review. He also provided guidance on how authors of primary studies could help systematic reviewers (e.g. provide more background information on context). In a private email, four days later, Robert thanked Atle and Sophie for their feedback in the CoP and concluded: "We are very happy that a serious discussion about how to accompany the promising PBF developments in many parts of the world with serious research is now well underway. Of course, you understand that I still beg to differ on a variety of points with you, but at least a dialogue has been opened which we really welcome. (...) We are looking forward to further debates with you and thank you once again for at least having recommended further research in this field. There, we fully agree!"

 
On August 25th, after the announcement by a member of the approbation by the Burundian parliament of an IDA grant of US$ 14,8 million for PBF, the Google group discussion veered off into another direction – on the sustainability of PBF, in French first. 

Obviously, though, the discussion on the best research strategy for PBF interventions will go on. Feel free to contribute via the comment section.


3 Commentaires

Un débat en ligne sur “le Financement Basé sur la Performance dans les pays à revenu faible ou intermédiaire: toujours plus de questions que de réponses”

9/23/2012

2 Commentaires

 
Un des deux éditoriaux du numéro d’août du Bulletin de l’OMS était consacré au  Financement Basé sur la Performance (FBP). Fretheim et al.  y rapportaient les principaux résultats de leur revue systématique Cochrane publiée quelques mois plus tôt. Les semaines qui suivirent – en dépit d’une torpeur  toute estivale et du départ en vacances de beaucoup d’experts – un débat s’est  tenu (en anglais) sur le forum de discussion en ligne de la communauté de pratique FBP  (CoP). Cette discussion a bénéficié  des contributions de deux auteurs de la revue systématique (Atle Fretheim et Sphie Witter). Cet article résume les principaux points discutés. Il essaie  d’être aussi objectif que possible.  Il est par ailleurs possible d’accéder à l’ensemble des emails (en anglais) sur la page Resources de ce  blog.

Bruno Meessen, 12 septembre 9 2012.


Le débat est lancé

Le 9 août, Emmanuel Ngabire (Ecole de Santé Publique, Kigali), co-facilitateur de la CoP partage l’article sur le groupe de discussion en ligne. La première réponse arrive deux heures plus tard, de Stefaan Van Bastelaere (Coopération Technique Belge, Bruxelles). Il exprime ses craintes sur l’impact possible de l’éditorial, et sa frustration: “Les auteurs réduisent le FBP à une stratégie qui génère de la quantité, selon moi, c’est injuste.”   

Bruno Meessen (Institut de Médecine Tropicale, Anvers), facilitateur principal de la CoP, invite alors les membres du groupe de discussion à lire l’article et à partager leur point de vue.

Longin Gashubije (Ministère de la Santé du Burundi, Bujumbura) s’interroge sur la définition restrictive utilisée par Fretheim et al. dans l’éditorial: “Je pense que le FBP est plus qu’un transfert d’argent; quand il est mis en œuvre correctement, il permet de transformer l’ensemble du système de santé ”. Il explique aussi pourquoi aucune étude aléatoire n’a été faite au Burundi: la simple observation, à travers le système de monitoring, de l’amélioration d’indicateurs quantitatifs et qualitatifs qui n’avait jamais bougé avant l’introduction du FBP s’est avérée suffisante pour persuader les décideurs d’étendre l’expérience pilote à l’échelle du pays. 

Les auteurs de la revue systématique veulent engager un dialogue

Le 10 août, Atle Fretheim (Centre Norvégien de Connaissance sur les Services de Santé, Oslo) rejoint le groupe. Après s’être introduit, il recommande à tous de lire également la revue systématique, pas seulement l’éditorial.  II exprime sa volonté de dialoguer sur comment les expériences FBP pourraient être évaluées d’une façon pratique, réaliste mais robuste.

Bruno Meessen réagit le jour-même. Sa frustration est palpable – l’essentiel de son long mail concerne justement le manque d’intérêt dont ont fait preuve les auteurs de la revue pour un tel dialogue avec les praticiens du FBP. En ce qui concerne la revue systématique, une meilleure connexion avec le terrain et les personnes engagées dans la mise en œuvre auraient évité certains malentendus.

Démarrage d’une discussion sur l’application de la méthodologie des revues systématiques aux réformes des systèmes de santé

Dans le même message, Bruno partage aussi sa vue personnelle, comme chercheur, sur les limites des revues systématiques une fois qu’elles concernent des stratégies de réforme des systèmes de santé. Cependant, il reconnaît que la discussion qui s’annonce sera bénéfique pour renforcer le programme général d’évaluation du FBP.

Le 10 août toujours, Sophie Witter (Université d’Aberdeen), première auteure de la revue systématique répond à Bruno.  “Comme chercheuse travaillant sur les systèmes de santé, je peux tout à fait comprendre tes frustrations avec le processus d’une revue Cochrane . Il a des forces et des faiblesses, comme toute méthode.”  Dans son courrier, elle rappelle à quel niveau les revues systématiques se situent dans le corpus de connaissance. Elle reconnaît que “c’était peut-être trop tôt pour le FBP, mais ces revues sont mises à jour régulièrement, ça ne devrait donc pas être un problème à long terme” et que “le FBP est une intervention particulièrement peu commode pour les revues systématiques, car il a été interprété de façons diverses et mis en œuvre dans des contextes très différents”. Elle ajoute : “ce sont tous des problèmes que nous avons soulignés dans la revue. Dans cette dernière, nous faisons un appel pour plus de recherche sur les effets systémiques et la relation aux différents contextes.” 

Le 11 août, Ir Por (Institut National de Santé Publique, Cambodge) – qui est alors juste en train de finaliser une revue (non-systématique) sur le financement basé sur les résultats appliqué à la santé maternelle et néonatale au nom de la Coopération au Développement Allemande – partage sa surprise “de voir autant de réactions sur l’éditorial mais pas sur la revue Cochrane elle-même quand elle a été publiée”. Por a lu la revue Cochrane, et il la trouve  “bien écrite, respectant des règles transparentes, et équilibrant bien ses résultats et conclusions. Dès lors, si nous voulons contester les résultats, il serait plus correct de contester les méthodes « Cochrane » (surtout pour la recherche en système de santé), mais pas les auteurs.”

Une revue systématique trop encline à inclure suffisamment d’études?

Après une semaine calme, le débat est relancé par Joanne Harnmeijer (ETC Crystal, Pays-Bas) le 17 août. Elle revient sur un point soulevé par Bruno : son analyse que la revue Cochrane est venue trop tôt. La discussion qui suit va alors permettre aux membres de la CoP de mieux comprendre certaines tensions internes à la revue systématique. Pour Joanne, la revue systématique est injuste : les auteurs ont inclus des données, rapports et études qui ne prétendaient pas nécessairement atteindre les standards d’une revue Cochrane pour ensuite à l’étape suivante du processus, correctement évaluer ces études comme atteignant un score faible en termes de rigueur.

Le même jour, Sophie Witter réagit, en fournissant plus d’information sur l’approche prise et comment elle respecte les standards Cochrane. Joanne répond le même jour, réitérant son analyse. Elle rappelle la pertinence de la recommandation d’ Atle d’avoir “un débat sur comment les expériences FBP pourraient être évaluées d’une façon pratique, réaliste, mais robuste” ; ses contributions relèvent de cette préoccupation.

Le mail de Joan déclenche aussi une réponse de Atle. Son commentaire à lui porte surtout sur les critères de sélection. Il rappelle les règles qu’une revue Cochrane doit respecter si elle porte sur une intervention sur le système de santé. Il écrit également : “Nous ne critiquons pas les auteurs des études originales. Ce n’est en tout cas pas notre intention. Que du contraire! Ils ont peut-être produit les meilleures études possibles compte tenu des circonstances. Je voudrais ajouter que nous sommes reconnaissants à de nombreux auteurs des études originales. Plusieurs d’entre eux ont répondu rapidement à nos emails et même envoyé leurs bases de données. Je pense qu’en général, les cherchant effectuant une revue Cochrane rencontrent bien plus de difficultés que nous n’en avons rencontrées quand ils essaient de dialoguer avec les auteurs des études primaires et d’accéder aux données non publiées. Donc, nous les remercions certainement !”

Toujours le même jour, Joanne répond à Atle. Le désaccord n’est pas évacué.

Comment prendre en compte les facteurs contextuels dans l’évaluation des experiences FBP? 

Le 21 août, Eric Bigirimana (AEDES et BREGMANS Consulting, Cameroun) revient sur l’importance du contexte dans la conception et l’efficacité d’un mécanisme FBP. Il illustre cela avec des observations faites par les participants d’une visite d’étude qu’il a organisé dans trois pays de l’Afrique des Grands Lacs. Eric est aussi chercheur. Il estime qu’une approche scientifique alternative – l’évaluation réaliste – prendrait mieux le contexte en compte que des études aléatoires. Dans son long mail, il explique pourquoi.

Sophie, qui est familière avec l’approche de l’évaluation réaliste (elle est actuellement coordinatrice d’un projet de recherche sur les politiques de gratuité en santé maternelle qui en partie, recourt à cette approche) répond: “Je pense que l’approche réaliste est très intéressante et je suis d’accord qu’elle pourrait bien s’appliquer au FBP. Pour la méthode Cochrane, s’il y a assez d’études robustes, alors vous pouvez regarder les patterns contextuels qui émergent. Malheureusement, si vous n’avez que quelques études (comme c’est le cas avec la revue FBP), ceci est exclu. Mais je voudrais juste noter que la méthodologie en elle-même n’est pas incapable de prendre en compte les différences contextuelles”.

Contribution de Robert Soeters: une synthèse, quelques autres critiques et une piste pour aller de l’avant en matière de recherche 

Le 22 août, Robert Soeters (SINA Health, Pays-Bas) envoie sa contribution. Dans son long mail, Robert fournit de l’information sur comment il a été impliqué dans le processus de la revue Cochrane. Son sentiment est que les chercheurs faisant la revue n’ont pas été transparents à la hauteur de son propre engagement à être transparent. Accorder aux chercheurs de terrain l’opportunité de donner un feedback précoce sur la revue aurait été un mécanisme de validation précieux. Robert explique aussi comment le savoir actuel sur le FBP a été développé graduellement sur le temps via une accumulation d’expérience. Il note qu’une large adoption de bonnes pratiques est un autre type de validation, une validation en termes de pertinence. Son évaluation de la revue est que “le résultat est un ensemble biaisé de recommandations et certaines conclusions qui sont communiquées hors de leur contexte.” Il développe ce dernier point en fournissant plus d’information sur plusieurs pays dans lesquels il a travaillé ces dernières années. 

Dans le reste de son message, Robert met en avant plusieurs idées pour une autre approche de la recherche sur le FBP. Il formule plusieurs inquiétudes, qui doivent être prises en compte pour l’agenda futur. Une est de trouver des stratégies de recherche qui ne nuisent pas au processus politique. Par exemple, l’échantillonnage de districts plutôt que de formations sanitaires au sein d’un même district ou encore une mise en œuvre progressive du FBP “par  laquelle un nombre de districts est inclus dans l’intervention et un nombre de districts pas (encore) inclus.”

Pour les revues systématiques, il insiste sur le fait que les interventions étudiées doivent être homogènes.  “ il y a un consensus grandissant dans les pays  à revenu faible ou intermédiaire sur la définition du FBP. Il faut éviter que des études de projets ne correspondant pas à cette définition soient incluses. Cela n’aide en rien d’inclure un projet non FBP et puis d’en tirer des conclusions sur le FBP. Je pense en particulier à une étude sur l’Ouganda (Palmer et al) et la Zambie (Revue Cochrane).” Comme d’autres, il souligne l’importance du contexte. Il conclut en marquant son adhésion à l’objectif commun de travailler sur les méthodes de recherche. “Nous invitons le monde académique à participer de façon constructive sur les réformes sanitaires FBP et par là, améliorer l’agenda scientifique.”

Une lettre de réponse par Atle et un engagement partagé pour un programme de recherche sur le FBP

Le même jour, Atle répond à Robert, point par point (cependant, pour une raison inconnue, le mail n’est jamais parvenu au groupe de discussion). Dans son mail, Atle rappelle aux membres de la CoP certaines règles des revues Cochrane. Il fournit aussi une guidance sur comment les auteurs des études primaires pourraient aider les chercheurs conduisant des revues systématiques (par ex, en fournissant plus d’information sur le contexte). Dans un mail privé, 4 jours plus tard, Robert remercie Atle et Sophie pour leur feedback et conclu : “Nous sommes très heureux qu’une discussion sérieuse sur comment documenter rigoureusement les développements prometteurs du FBP dans de nombreux endroits du monde soit désormais bien lancée. Bien sûr, vous comprendrez que sur une variété de points, je reste en désaccord avec vous, mais au moins un dialogue est entamé – quelque chose que nous accueillons sincèrement. (…) Tout débat ultérieur reste le bienvenu et nous vous remercions également pour la recommandation que plus de recherche soit entreprise – sur ce point, nous sommes pleinement d’accord.”

Le 25 août, un des membres de la CoP informe le groupe de discussion de l’approbation par le parlement burundais d’un don de 14.8 millions de dollars de la Banque Mondiale. Le groupe de discussion en ligne abandonne alors spontanément le débat sur l’étude Cochrane pour discuter la problématique de la pérennité (en français cette fois !).

Manifestement, la discussion sur la meilleure stratégie de recherche pour les interventions FBP continuera. N’hésitez pas à contribuer via la section « commentaire » de ce blog.
 
2 Commentaires

Regional Conference on Social Health Protection in East African Community

9/20/2012

4 Commentaires

 
By Richard Alia

In this blog post, Richard Alia (from the Great Lakes Initiative on AIDS, Kigali, Rwanda) reports on the recent conference on Social Health Protection in Kigali. He is worried that the goal of Universal Health Coverage may not be achieved in the near future in the East Africa Region due to weak health systems, poor road infrastructure and lack or high cost of transport to the care and treatment centers for the rural population. Besides, health expenditure is escalating and technology is one of the major reasons.


Social health protection (SHP) is critical to human welfare and sustained economic development. It also contributes to global peace and security. Yet in some countries up to 11% of the population suffers from catastrophic medical expenses each year and up to 5% is forced into poverty. In 2005, the World Health Assembly resolved that everyone should have access to health services without having to suffer from financial hardship in the process. This was reinforced by the 2010 World Health Report, Health Systems Financing: the Path to Universal Coverage; and further, by a 2011 World Health Assembly resolution, Sustainable Health Financing Structures and Universal Health Coverage (UHC).  

Regional Conference on SHP in East African Community


A 2-day conference on SHP in the East African Community (EAC) was held in Kigali, Rwanda from September 11-13, 2012. It focused on the efforts of EAC countries to provide SHP to their respective populations and their achievements and challenges. The event also provided recommendations on how to effectively support the development and harmonization of SHP and SHP mechanisms in the EAC region.

The overall objective of the  conference  was to highlight  various  approaches for the development and implementation of  comprehensive  and equitable  SHP systems  for  the EAC and to recommend  policy options in developing regional mechanisms  aimed at building  a strong and harmonized system of SHP. Specifically, the conference contributed to the ongoing evidence-based approach of the EAC to meet SHP needs of its population, as the region strives towards UHC and access to health services. Consultations were also made on effective harmonized implementation of SHP and how to collaborate towards a stronger regional system of SHP.

The Conference targeted key stakeholders of SHP in Burundi, Kenya, Rwanda, Tanzania and Uganda. This included government policy makers from health and health related ministries, EAC officials and national authorities, SHP/health insurance organizations, representatives of health care providers, civil society organizations, Community of Practice members, academic institutions and development partners.

Key note speeches were delivered by guest speakers , including Joe Kutzin (WHO – Geneva), Jean Olivier Schmidt (GIZ), Richard Sezibera (SG of EAC), Claude Sekabaraga (World Bank), Lydia Dsane-Selby (Ghana National Health Authority),  and Jens Holst (EU). In addition, representatives from the EAC countries shared experiences from their respective countries. Ministers of Health from the EAC countries also held a closed-door discussion and produced a Ministerial Statement on SHP/UHC in the EAC Region.

Some of the key observations made on SHP/UHC during this conference.

Everybody agreed that the main goal of SHP/UHC is to improve health outcomes, productivity hence economic development. Kutzin emphasized that UHC is not a new concept but emerged in particular after World War II where Europe began pushing for social cohesion, Japan for a concept of human security; and the WHO Alma Ata conference coined the slogan of Health for All by the Year 2000.

Participants agreed that UHC is a destination, it might take a bit of time to get there, but every country must aim at the same goal although they might be at various levels/stages at any one time. The pillars of UHC are: Access, Quality, and Financial Protection, but even developed countries cannot meet these objectives all at once. The situation is worse in developing countries. However, UHC is a journey that all the EAC countries are already on; this must be commended.

It was clear from this conference that SHP is a pre-requisite for UHC  and that quality of services is part and parcel of SHP/UHC.  There is a relationship between financing and the quality of health care services. Community Based Health Insurance and Performance Based Financing play key roles here.

Some of the requirements for SHP/UHC are: vision, leadership/strong governance and legal framework; there is a need for a whole health system approach going beyond health financing e.g. capacity building for human resources for health and service infrastructure development. For instance, the success of Thailand with UHC was built on long term programmes including capacity building and service infrastructure development.

Overall assessment of the conference

This was a good conference in the sense that it brought together policy makers and key stakeholders from the same region to discuss the roadmap to SHP/UHC. By identifying key strengths, opportunities, and weaknesses in this region together and finding ways of utilizing or mitigating them accordingly, a great job was done. Besides, by involving the development partners in the EAC region such as GIZ, WHO, USAID, Clinton Foundation, MSH, and BTC, a clear message was sent that the journey of SHP/UHC is a joint venture.

One of the objectives of the conference was to make progress towards harmonization of some strategies in the EAC region. However, as it was clear from the conference experiences of EAC Member States in providing SHP vary: some have well established compulsory, publicly managed, health insurance programs with substantial transfers from general budget revenues; some governments also fund services, often directly through the supply side, but others also use PBF methods; and some even have robust private health insurance markets. These differences highlighted the fact that the specific path towards SHP/UHC differs from country to country; hence there is no single best solution that applies to all of them. However, best practices and lessons learned during the implementation processes are important to be shared in order to improve EAC systems for SHP to meet each country’s specific needs, but also to enhance harmonization across the region. According to Jens Holst who shared the experience of harmonization of SHP in the European Union, harmonization can take place without having the same system. Therefore, harmonization of SHP strategies within the EAC Region is feasible.  

Another challenge that the EAC faces in its journey towards SHP/UHC is the status of its health systems. As mentioned above, UHC is not just a health financing issue. My worry is that given the fact that the health systems in this region are still weak – as evidenced by poor infrastructure, lack of human resources, and frequent lack of drugs and other health commodities in most health facilities - and the fact that the costs of healthcare are escalating due to new technology, achieving SHP/UHC objectives is still a long way to go.  In addition, poor road infrastructure and lack or cost of transport in the rural areas will still be a challenge to accessing health care by the poor. Nevertheless, it was agreed during this conference that a situation analysis and feasibility studies be conducted in the EAC countries to establish the status of SHP/UHC in each country and thereafter plan the strategies for harmonization of approaches of SHP/UHC in the East Africa Sub Region.

As for the ways forward, country cases of course inspired much of the discussion in Kigali. The cases of Rwanda which combined community based health insurance and PBF or Burundi which linked PBF to selective free health care got their fair share of attention. However, complementary schemes such as conditional cash transfers, cash refunds, voucher cards, strengthening community health systems,  scaling up outreach services, etc. should be considered if we are to reach the poorest. Nevertheless, all conference participants agreed that UHC does not mean everything is free for everyone, everywhere, and all the time.

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Upcoming FAHS CoP workshop in Marrakesh: Equity in Universal Health Coverage – reaching the poorest

9/12/2012

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by Allison Kelley

What do we know about how to effectively cover the poorest? What are the options? How can equity in UHC be measured? From September 24th to 27th, around 80 international experts from 12 countries will gather in Morocco. They will work on strategies to ensure that health systems reach the poorest. In this blog post, Allison presents the main objectives of the workshop. 

There is enormous global interest today in “universal coverage”, which was the theme of the 2010 World Health Report, the just released Lancet series, as well as of a number of international and regional conferences over the past 18 months, including several focusing specifically on Africa.  One key question remains that of access to health care for the poorest, sometimes referred to by policy makers as “indigents”. If the term indigent, whose genesis goes back to the origins of welfare systems, is ambiguous, its definition is clear in the health care sector: individuals who do not have the means to pay for health care and for whom coverage, directly by health care providers or indirectly by prepayment systems, requires public intervention.

Given thus that a large percentage of the population still lives below the poverty line and often up to 80% of households depend on (irregular) incomes in informal sectors in many African countries, combined with severe institutional instability in some cases, reaching universal coverage is challenging for African governments to say the least. Nevertheless, the tangible progress achieved by certain countries such as Rwanda and Ghana demonstrates that universal coverage is not only an economic problem: if political will is sufficiently strong, it is possible to make significant progress to reach universal coverage even with limited resources. However, even in Ghana and Rwanda, where coverage rates are high – around 65% and 90% of the total population, respectively – the poorest are often excluded from national health insurance schemes. Although specific measures - such as exemptions – are implemented to ensure their coverage, these actions remain generally ineffective (1). In Ghana, despite an exemption policy aiming to cover indigent and vulnerable populations, only 1.4% of the indigent population is covered by the National Health Insurance Scheme (2).  

African countries are currently experimenting with a number of approaches and mechanisms to improve access to health care for this target population: equity funds, subsidies for health insurance premiums, health care vouchers and even cash transfers. However, none of these mechanisms has yet proved successful in improving access to health care for the poorest on a national scale, highlighting the challenges to reach universal health care coverage.

In co-operation with the Moroccan government and the Joint Learning Network for Universal Health Coverage (JLN), the Financial Access to Health Services Community of Practice (FAHS CoP) is organizing a workshop on the subject of “Equity in universal health care coverage: how to reach the poorest”, which will take place from 24th to 27th September 2012 in Marrakesh, Morocco.

The workshop will bring together representatives of 8 African countries (Anglophone and Francophone) and several resource countries (Asia and South America), as well as CoP members and regional institutions. The workshop will place the emphasis on peer learning and will promote in-depth exchanges between countries and among the various actors within each country. The workshop will also include site visits in order to observe the implementation of RAMED, the Moroccan medical assistance program for the poor. 

Like other knowledge activities of the CoP, the workshop will build on discussion, exchange and experience sharing among participants.
Specifically, the Marrakesh workshop objectives are to:
- Place equity within the policy framework of health care financing;
- Identify and document efficient strategies implemented to ensure coverage of the poorest (from African countries and other countries if relevant);
- Diagnose how and why mechanisms intending to cover the poorest have been less successful than desired and seek solutions to overcome weaknesses;
- Identify gaps in knowledge concerning coverage of the poorest and define research priorities;
- Analyze the focus on the poorest populations and link measures taken to national universal health coverage;
- Support participating countries in drawing up action plans to improve their policies on access to health care for the poorest.

As usual, the FAHS CoP will “broadcast” from the workshop on the Google group ([email protected]) and on the HHA web platform, providing daily updates, interviews, and content, so do stay tuned!

Notes:
(1) Morestin F &Ridde V (2009). How can the poor be better integrated into health insurance programs in Africa? An overview of possible strategies.Université de Montréal.
(2) Presentation given by Sylvester Mensah, Chief Executive, National Health Insurance Agency, Accra, Ghana at the November 2011 PanAfrican Health Congress on Universal Coverage in Accra.

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Researching the Bamako Initiative: Vincent Okungu interviews Professor Lucy Gilson

9/3/2012

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Picture
Over 25 years, the Bamako Initiative receives a lot of attention by researchers. In the weeks to come, we will post interviews of a few experts who by their empirical work were important contributors in the related scientific debate. This week, Vincent Okungu talks to Professor Lucy Gilson, from the University of Cape Town and the London School of Hygiene and Tropical Medicine. 

VO: In the 1990s, you were much involved in documenting the Bamako Initiative (BI) experiences at country level. Retrospectively, how do you assess this involvement as a researcher?

LG: It was an important opportunity to understand and document the BI as a key initiative seeking to improve health care quality, but also introducing user fees. The BI was definitely intended to be what we would call today a system level initiative, and that was, for me, a positive approach - but the use of fees concerned me. In my previous work I had already raised concerns about fees as a deterrent to access and so wanted better to understand if and how the BI might work to improve access for the poor despite using fees. The study I coordinated also included Francophone and Anglophone African experience and that was important and interesting. The BI work thus extended my earlier work on user fees and exemptions. In addition, it specifically adopted a policy analysis approach better to understand the forces driving and limiting implementation. This work remains therefore, one of the few examples of a multi-country, actor and process-oriented evaluation of a system-wide intervention.

Was this work commissioned by the promoters of the BI? What was the relationship with them? And with countries?
It was not commissioned but it was funded by UNICEF. To be honest, I cannot remember if there was a closed or open call for applications, but I certainly submitted a proposal for review - and a proposal that reflected what I felt would be appropriate questions and methods (rather than one responding to specific terms of reference). UNICEF was an interested but not interfering funder. The proposal involved work in three countries, in each of which there were country teams who led all country work, including engagement with national policy makers, adapting the common umbrella-type proposal to the specific situation of each country.    

What was your approach in terms of methods and the main lesson in this respect?
As noted above, this was predominantly an actor and process oriented evaluation applying the Walt and Gilson policy analysis triangle and largely using qualitative methods. Impact data were sourced from prior studies and evaluations, rather than conducting large scale household level survey type work. However, there was some smaller scale household level work (focus group discussions and some survey work) to understand the impact on access in selected local areas. Overall, however, the primary intention was to understand why and how the BI programme in each country worked as it did, influenced access and equity in the way it did, and not to investigate primarily what its impacts were. Partly this was because other impact type evaluations were available. More importantly, however, the premise was that understanding how and why implementation occurs offers better insights into how to manage system reform than impact evaluation, which instead address the question of whether or not a programme/intervention should be implemented at all. I remain convinced that we need more health system evaluations asking how and why questions - that we do not have enough such evaluations - and that these are well informed by policy analysis theory and require qualitative data collection approaches.

According to you, what were the most important findings by your group?
I think it shows the differences in experience between Francophone and Anglophone settings and as too few studies combine work in both types of settings, this is important. And ultimately I think it shows how local level actors, often regarded as relatively powerless in health systems, have critical roles in implementing policies intended to benefit the poor - and how local contexts are very influential in this regard. And I think it shows how centrally led planning is never enough to secure local level gains but nonetheless can offer important guidance for local level action, when and if it allows for/takes account of local level contexts.

Retrospectively, do you think that you missed some issues?
Oh no doubt! No study can cover everything. And every study is always a building block in wider understanding.



For those willing to read (again) Lucy Gilson’s papers:

Gilson L, Kalyalya D, Kuchler F, Lake S, Oranga H and Ouendo M (2001) Strategies for promoting equity: experience with community financing in three African countries. Health Policy 58: 37-67.

Gilson L, Kalyalya D, Kuchler F, Lake S, Oranga H and Ouendo M (2000) The equity impacts of community financing activities in three African countries. International Journal of Health Planning and Management 15: 291-317


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