Financing Health in Africa - Le blog
  • Home
  • Bloggers
  • Collaborative projects
  • Join our COPs
  • Resources
  • About Us
  • Contact Us

Communities of practice, towards a more decentralized organization

5/4/2015

2 Commentaires

 
PhotoFigure 1. New organizational system for CoPs (on a fractal design)
Facilitation team

The new ambition of the CoPs is to increase opportunities for the CoP experts, through the launch of different collaborative projects. However, to make this transition possible we also need to reorganize our facilitation structure. In this blog, we present you the model towards which we are heading. If you have been with us for some time already in our CoP, there might very well be a new role for you!

The limits of the current model

In a recent blog, Bruno reviewed the five years of existence of the CoP Performance Based Financing (CoP PBF). He mentioned among other things how he has become sort of a bottle neck himself  as a key instigator and focal point of PBF CoP activities. In recent years, we have tested models with better equipped facilitation teams.   The Financial Access to Health Services CoP (CoP FAHS) went furthest in implementing this model. In the end, however, this approach did not lead to the expansion we expected to get.

In Rabat, we discussed this model of organization. For the PBF, FAHS and Health Services Delivery CoPs, the diagnosis was clear: so many of our beautiful projects have been put on hold due to our non-availability. We see the future in the model that was launched last year during the « Results Based Financing & Information Communication and Technology » workshop that was led by an autonomous central facilitation team.

The new model

To get rid of the bottle neck of facilitators, our new strategy will involve an organigram of facilitation that allows delegation of more responsibilities (the word « organigram » is not very appropriate as CoPs are not conventional organizations with a hierarchy and employees, but we could not find a better word for the time being). We are going to move away from our flat “rake” organigram towards a more decentralized organigram (see figure 1).

In practice, from now on, each activity of the CoP will be  conceived as a collaborative project. This project will be assigned to a “project manager”  (by the way, we find the term « project manager » not very original, and we will reward anybody among you who comes up with a better one with a PBF T-shirt – just offer your suggestions as comments to this blog). The main responsibility of the “project manager” will be to see the project through, from start to finish. These new project manager posts will be new opportunities for our more experienced and motivated experts. They can show their passion for knowledge management and their will to help the more junior experts to grow (in terms of knowledge, competences, …).

The selection of « project managers » will take into account the nature of the projects. In fact, as you’ll gradually discover as the collaborative projects will be shared online in the coming weeks and months, these projects will be of a different nature. Some will be relatively short, others will last for quite some time. Some will be small projects, others will be much heavier. Some projects will require both English and French, others not. Also, some will be more technical, others less. The title of “Project manager”  will thus be confined in terms of content and time. You should note that the expert who will have accepted this responsibility will have in advance agreed to precise terms of reference. He or she will also undergo an evaluation of his/her own performance (by his/her colleagues experts involved in the project).

Implementation

This model will be gradually implemented. The speed will depend, among other things, on the volume of collaborative projects that we will be able to launch. Obviously, it is possible that all will not work  smoothly from the beginning, but the most important is to start embracing this transition and take a decisive move forward, towards this new CoP development. We count on your support to succeed in this new model of facilitating CoPS.


Translation: Seleus Sibomana

2 Commentaires

Ebola: Can we contribute in any way to the fight against this epidemic?

9/22/2014

5 Commentaires

 
CoP facilitation teams

For many of us, the month of August was probably when we realized that we were dealing with an epidemic without precedent. As time goes by, the nightmare just continues to unfold in Liberia, Sierra-Leone, Guinea and in the most remote areas of DRC. In Liberia, from September 1-7, almost 400 confirmed and probable cases of Ebola were reported – a figure which represents almost double the number of newly reported cases the preceding week. Just in Liberia, the transmission of the virus is increasing at an exponential rate, and we  know  that  reported  cases within  the health  system are most likely an underestimation of the total number of cases in reality. The heavy toll paid by healthcare workers makes this epidemic even more frightening. On September 9 in DRC, 35 Ebola deaths were registered, of which 7 were healthcare personnel. By September 14th in Guinea, 60 healthcare personnel had been infected by the virus, of whom,30 succumbed to the disease. Last week, a researcher from Guinea shared his experience with us about how an obstetrician, two midwives and a young trainee got infected with the virus while attending a delivery. The truth is that the entire health system is blocked by this crisis, and is barely functioning in Liberia and in Sierra Leone. As a result, many are dying of malaria or during childbirth.

We have all observed the delays and the insufficient scale of the response from the international community. Ebola is even overwhelming the many international actors who are adept at assisting in humanitarian crises. Doctors Without Borders, an organization that has been at the forefront of the fight against this epidemic, has been calling for help: they are overburdened. In the North, we are also seeing reactions inspired by fear or by selfishness: some even saying “keep these sick individuals far away from us!”

What can we do? 

The situation is of great concern to our communities of practice. We know that some of our CoP members are based in the  countries heavily affected by this epidemic.  We  also know that in neighbouring countries, many health specialists are already preparing a response to bolster the health system in case Ebola reaches them. Other members may be further away from the battlefield, but we anticipate that all of us will soon be more involved in the struggle against Ebola as the situation is only getting worse.

Our message is simple: the CoPs are ready to engage in the fight against Ebola. But we want to engage only insofar as it is useful. We are aware of our limitations, and we do not wish to add to the chaos. But if those of our members involved in the struggle against Ebola on a daily basis believe we can constructively play a role, we are open and ready to help.

First ideas

One positive role we can have is to listen to the needs of those actors directly involved on a daily basis within the health system, especially the needs of healthcare workers. We can help to communicate and share messages, needs and experiences. Our conviction is that today more than ever the voices of those who are on the ground need to be heard, loud and clear. What challenges do you face on a daily basis? What are you observing on the ground? What best practices have been identified in the various contexts you work in? How is the response against Ebola currently organized and implemented in your districts and in your hospitals? Is there any need to improve the response of international partners (for example by reducing or avoiding wastage)? We believe that the online forums we have established could be useful for this purpose.

Another way we could engage is to draw on the expertise of the 3000+ health professionals in our CoPs. For example, an expert working with an international organization contacted us recently to request support in preparing a concept note on motivating health personnel in Liberia (Liberia’s health staff recently went on strike because of the risks they face with this epidemic). We rapidly contacted several senior experts of the PBF CoP. They gave their inputs on the initial memo, and helped to clarify what is possible through financing mechanisms, and what should be done through other means. We stand ready to offer this sort of expertise to others, particularly Ministries of Health.

This quick consultation among CoP members also revealed that many have concrete and hands-on experience in the Ebola response.  We invited some members to share their experiences on our forums and we hope to post their contributions in the coming weeks. This could be a third type of contribution to the Ebola response. We are especially concerned about mobilizing community health responses. How can we ensure the voices of the population are heard? How can we help them mobilize their local resources and plan and implement their own response strategies?

Last but not least, we want to ensure that our forums serve as places for discussing and sharing key technical documents. On the “Health Systems Planning & Budgeting” CoP’s on-line forum, health experts have been weighing whether to organize national immunization days in Cote d’Ivoire, a country that borders the epidemic’s epicentre. The Health Service Delivery CoP has already published several blog posts on the issue, and recently published a list of 5 useful articles on the topic (in French).

We will surely maintain such efforts. Several of us will be in Cape Town for the “Health Systems Research Symposium”. During our satellite session on Monday September 29, we have set aside time to discuss the Ebola situation and our response. In the meantime, we invite you all to respond and share your views on this initiative. If you believe that the CoPs have a role to play, and if we can clearly delineate this role, the first step  will  be  to  create  an  inter-CoP task force.  We will  then   seek  volunteers  to  strengthen  the coordination of this initiative.


We look for your guidance, please leave a comment or react on your online forum.

5 Commentaires

Mapping fragmentation of health care financing in 12 Francophone African countries

9/17/2014

4 Commentaires

 
Picture
Allison Kelley

For the past year, experts from 12 Francophone African countries (1) have been working together on a project related to health financing fragmentation in their countries. In this blogpost, the first in a series, Allison Kelley (lead facilitator of the CoP Financial Access to Health Services) presents the main results from the first phase of this project, with a focus on cross-country findings. 


Last November on this blog, we introduced you to a collaborative project that two CoPs (Performance-Based Financing and Financial Access to Health Services) were launching on the challenge of Universal Health Coverage (UHC).

The project, financed by French Muskoka Funds and the NGO Cordaid, was a first for the CoPs: a chance to test our capacity to document a specific issue – health financing fragmentation – across a large number of countries. The hypothesis being that by their very nature and the size of the networks they represent (the PBF CoP has 1,500 experts, the FAHS CoP 800), CoPs could usefully complement the research and documentation activities being carried out by other actors (research institutes, aid agencies…) This first blog focuses on the results of the cross-country analysis from Phase 1 (2).

Universal Health Coverage: a big misunderstanding?

By its very definition, progress toward UHC means progress in three main dimensions: (1) the number of people covered (2) the comprehensiveness and quality of the package of services covered, and (3) the reduction of out-of-pocket payment at the point of service. How to move toward UHC, on the other hand, is sometimes misunderstood, with some thinking that it simply consists of introducing a single, universal, mandatory health insurance system.  In fact, the reality in all countries is that populations today are benefitting from some “coverage” through the various health financing schemes (HFS) that already exist. Moving toward UHC will be more a process of bringing order and efficiency to the HFS that already exist than it will be of introducing yet another one.

Mapping the situation in 12 Francophone countries

As a reminder, the objective of our project’s first phase was to carry out a mapping of HFS in 12 Francophone African countries, or almost a quarter of the continent. To reach a complex destination such as UHC, one must have a clear idea of the starting point!

The full Phase 1 report is now available (under the “resources” tab of this site). The cross-country analysis was drawn from the country documentation carried out by national CoP experts (3). Phase 1 produced useful lessons, and confirmed that we are indeed facing a tangle of HFS.

* Our study documented serious fragmentation in HFS in African countries today. Based on our method of counting, there are on average 23 HFS per country.

* Beyond simply counting the number of HFS (which was not easy in and of itself), carrying out this mapping exercise was more difficult than we had anticipated: in many countries, we encountered serious problems in accessing information on HFS. Financing information was frequently missing or unavailable. This lack of information not only hampers government leadership in piloting UHC, but also makes it difficult to get a sufficiently accurate understanding of what is a complex situation in each country, and so concrete suggestions for improving the coordination of HFS remain difficult to formulate.

* Our mappings show that in most countries there are both gaps in population coverage (people with little or no coverage) as well situations of overlapping coverage (certain population groups with coverage through multiple HFS). A common example is a civil servant already benefiting from health insurance who gives birth is a hospital with a fee exemption for deliveries. The vertical nature of the services covered and the narrow targeting of the population groups covered results in very “partial” coverage that often lacks continuity from a therapeutic perspective. 

* There is an alarming lack of coordination and continuity in terms of provider financing modalities among HFS; this is a serious obstacle to effective expansion of UHC.

* Our mapping shows a heavy dependence on external financing for health. This has a considerable influence on the structure of health financing and can exacerbate fragmentation not only in terms of the number of schemes, but also in terms of governance for health financing. The dramatic rise in vertical programs translates into not only a verticalisation of HFS and their respective benefits/services covered, but also a lack of centralised information at the Ministry of Health regarding these externally-funded HFS.

A shared challenge, but no common pathway to UHC…

The overall result of Phase 1 is thus to highlight a major challenge that all 12 countries are facing. The profusion of HFS, but also the current lack of coordination among them (as evidenced by the unavailability of centralized, transparent data), makes us conclude that significant progress toward UHC will be complex to achieve: order will have to be brought to the current tangle of HFS – some will need to be merged, others ended altogether….

And to bring order, many stakeholders will have to come together around the table – numerous Ministries and public agencies, the multiple programs and their various funders, private actors (like mutuelles), representatives of professional associations….

The bottom line is that no one solution exists for moving toward UHC. Each country’s path will be different.

Of one thing we are sure, and this is valid for all countries wanting to make serious progress toward UHC: governments, and Ministries of Health in particular, must develop significant, operational capacity to collect information, to analyse it, and to use it to guide decision-making. Knowledge management and the ability to analyse the situation - its strengths, constraints, opportunities, and threats – will be necessary conditions to achieve UHC.

As you’ll discover in an upcoming blog, these findings have had a major influence on the approach we’ve adopted for the second phase of this CoP collaborative project.


To access the report (in French, but with an executive summary in English), click here.


Notes :

1. Experts involved in this project ,In alphabetical order by country: H. Felicien Hounye  (Bénin), Maurice Yé (Burkina Faso), Longin Gashubije (Burundi), Isidore Sieleunou (Cameroon), Mamadou Samba (Côte d’Ivoire), Amadou Monzon Samaké (Mali), Mahaman Moha (Niger), Philémon Mbessan (Central African Republic), Ma-nitu Serge Mayaka (Democratic Republic of the Congo), Adama Faye (Sénégal), Salomon Garba Tchang (Chad), Adam Zakillatou (Togo).


2. In another blogpost, we will reflect on the lessons learned from this phase about the CoPs’ capacities.

3. To obtain information about country-level reports, please contact the experts directly (see Annex B of the cross-country analysis report).



4 Commentaires

Financement de la santé en Afrique Francophone : l’écheveau de des régimes comme point de départ pour la couverture sanitaire universelle

9/17/2014

6 Commentaires

 
Picture
Allison Kelley

Pendant un an, des experts issus de 12 pays d’Afrique Francophone (1), ont collaboré sur un projet relatif à la fragmentation dans le financement de la santé dans leurs pays. Dans ce billet de blog, le premier d’une série, Allison Kelley présente les principaux résultats de la première phase du projet et plus particulièrement l’analyse transversale des études-pays. 


En novembre dernier sur ce blog, nous vous avions présenté un projet collaboratif que deux CoP (financement basé sur la performance et accès financier aux services de santé) lançaient sur la problématique de la Couverture Sanitaire Universelle.

Ce projet, financé par le Fond Français Muskoka et l’ONG Cordaid, était pour les CoPs une première : il s’agissait de tester notre capacité à mener à bien un travail de documentation d’une situation particulière (la fragmentation du financement de la santé) dans un grand nombre de pays. Notre hypothèse est que par leur nature et le réseau qu’elle constitue (la CoP FBP compte désormais 1.500 experts, la CoP AFSS 800), les CoPs peuvent compléter les travaux de recherche et de documentation mené par les autres acteurs (centres de recherche, agence de l’aide…).  Dans ce premier blog, nous partageons avec vous les résultats de l’analyse transversale des études-pays.

La Couverture Sanitaire Universelle : un gros malentendu

Par définition, progresser vers la couverture sanitaire universelle (CSU) revient à progresser sur au moins trois grandes dimensions : (1) le nombre de personnes couvertes (2) la composition et la qualité du panier de services de santé auxquelles elles ont droit, et (3) la réduction de la contribution financière directe engendrée par le recours aux soins. Cette progression est souvent mal comprise, certains pensent par exemple que progresser vers la CSU consiste à introduire un système d’assurance obligatoire universelle unique. La vérité est que dans chaque pays, grâce aux régimes de financement de la santé (RFS) existants, la population bénéficie déjà, dans une certaine mesure, d’une couverture. Progresser vers la CSU consiste donc bien plus à apporter cohérence et efficience dans la combinaison de ces RFS déjà en place que lancer un RFS de plus.

La situation dans 12 pays d’Afrique Francophone

A titre de rappel, l’objectif de cette première phase de notre projet « Muskoka » était d’établir la cartographie des régimes de financement de la santé présents dans 12 pays africains francophones, soit presqu’un quart du continent. Pour atteindre une destination comme la CSU, il faut d’abord connaître avec précision son point de départ !

Le rapport des résultats de la première étape est désormais disponible (voir la rubrique "Resources" de ce site). L’analyse transversale capitalise sur la documentation individuelle de chaque pays par des experts nationaux des CdP. (3) Cette phase a été riche de leçons. Elle confirme que nous sommes bien face à des écheveaux de RFS.

* Notre étude a confirmé la grande fragmentation des RFS aujourd’hui dans les pays africains. Selon notre méthode de comptage, nous avons en moyenne 23 RFS par pays.

* Au-delà du simple comptage (qui nous a déjà bien occupé), dresser cette cartographie a été plus difficile que prévu : dans plusieurs pays, nous avons buté contre le problème de la disponibilité des informations sur les mécanismes de financement de la santé. L’information financière est souvent lacunaire. Cela freine le leadership de l’Etat dans le pilotage de la CSU et entrave une bonne compréhension à tous les niveaux de cette situation complexe, et donc aussi une meilleure articulation des mécanismes de financement.

* De fait, nos cartographies montrent que dans beaucoup de pays, coexistent simultanément des « trous »  dans la couverture de la population (personnes non couvertes ou très peu couvertes) et des redondances (certains groupes bénéficiant d’une possible prise en charge par plusieurs RFS). On peut citer l'exemple d'une fonctionnaire qui dispose d'une assurance-santé et accouche dans un hospital où l'accouchement est gratuit. La verticalité au niveau des prestations prise en charge et la sélectivité des populations ciblées se traduisent en couverture très partielle, qui ne garantissent pas une continuité dans la prise en charge thérapeutique.

* Nous avons également constaté un manque de cohérence en termes de prévisibilité et régularité des modalités de financement des structures de soins; cela constitue un obstacle important à l’extension effective de la CSU.

* La majorité de ces RFS ont un financement dépendant de l’extérieur. Cela a une influence considérable sur la structure du financement de la santé et aggrave non seulement le problème de fragmentation, mais aussi celui de gouvernance du financement de la santé. Le rôle dominant des programmes spécialisés entraine la verticalisation de la prise en charge et le manque de centralisation au niveau du Ministère de la Santé des informations, notamment financières, gérées par les bailleurs extérieurs.

Défi commun, mais chemin individuel vers la CSU…

Le résultat général de cette phase est de faire ressortir un défi commun aux 12 pays de l’étude.  Cette profusion de RFS, mais aussi les insuffisances actuelles au niveau de leur coordination (comme le prouve l’absence de données centralisées et ouvertes à tous), nous laissent penser que dans de nombreux pays, progresser vers la CSU va être complexe : il va falloir remettre de l’ordre dans tous ces RFS : en fusionner certains, en arrêter d’autres…

Pour faire cela, il va falloir mettre de nombreux acteurs, autour de la table, plusieurs ministères et agences publiques, mais aussi des programmes multiples et leurs partenaires techniques et financiers, des organes privés (comme les mutuelles), des représentants des associations professionnelles...

Le défi est qu’il n’existe pas de solution unique en guise de chemin vers la CSU. Chaque cas sera particulier.

Nous avons une certitude, et elle est valable pour tous les pays: la progression vers la CSU va nécessiter les gouvernements, et les Ministres de la Santé en particulier, à développer une grande capacité à collecter de l’information, à l’interpréter et à prendre des décisions en concordance. La gestion des connaissances et l’aptitude à analyser sa situation, les forces, contraintes, opportunités et menaces seront des conditions nécessaires pour progresser vers la CUS.

Comme vous le lirez dans un prochain blog, cette analyse a grandement déterminé notre réflexion pour ce qui devra la seconde phase de ce projet mené par les CoPs. 



Pour accéder au rapport: cliquer ici.

6 Commentaires

Taking Results Based Financing from scheme to system: a multi-country study

9/10/2014

2 Commentaires

 
Picture
Bruno Meessen

This blogpost introduces a multi-country research project looking at how at country level, Results Based Financing (RBF) schemes move from pilot to full integration into national health systems. The study is led by the Alliance for Health Systems and Policy Research and scientifically coordinated by the Institute of Tropical Medicine (ITM) and will be carried out by national research teams of eleven countries.




Worldwide, more than 30 low or middle-income countries are today developing, within their health sector, experience with so-called RBF strategy. While a few of them have already moved to a full-fledged national policy, most of them are still in pilot stages. This large international movement is facilitated and boosted by a number of forces and positive synergies: political will, aid agencies’ leadership and financial resources, enthusiasm of experts, commitment of major stakeholders, pro-active knowledge management…

The main goal of every RBF scheme is to improve the performance of the health system (measured in terms of quality of the health service delivered, coverage rate…). The ultimate goal of every - successful - pilot scheme is to be scaled up. From a knowledge management perspective, though, a pilot scheme which failed to improve some target indicators is actually still a success if the operational lessons which have been drawn from the experience allowed stakeholders to improve the national health system. This is an outcome which matters for an RBF strategy, as many have argued that its transformative power is one of its key attributes. A key metric of the ‘success’ of an RBF experience should therefore be its ability, through the core principles it promotes, to reinvigorate the national health system. One can foresee transformations/scale up on many different dimensions.

Launch of a multi-country research project

The possible journey “from scheme to system” will be the main focus of a  multi-country research project coordinated by the Alliance for Health Policy and Systems Research and the Health Economics Unit of the Institute of Tropical Medicine. This research program is sponsored by NORAD, the Norwegian Aid Agency.

The call for proposals launched by the Alliance sparked quite some interest: 34 research teams submitted a proposal. Eleven countries have been selected – you can discover which ones by clicking here.(1) Selected research teams have been informed. The next step will be a protocol development workshop to which the principal investigators of the eleven countries will be invited. Together, we will explore the commonalities across the 11 cases and assess whether we can adopt a common framework and select a limited number of common research questions.

After approval of the protocols by ethical committees, each national research team will document how the journey from scheme to policy is going in their respective country (although among the 11 countries, we have also interesting stories of pilot schemes which did not materialize into national policies). While our sampled countries are mostly from sub-Saharan Africa (the most dynamic continent, as far RBF is concerned), we are happy to have also three experiences from outside Africa. In Africa, we will cover a nice mix of settings: a few post-conflict countries, some Francophone and Anglophone countries, a mix of small and big countries.

Our communication strategy

While the PBF Community of Practice is not formally involved in this research at this stage, we will make sure throughout this project to keep you informed about the progress being made. We are indeed very aware that moving from scheme to system is a challenge that some of you are already facing today. So you may learn from what we discover… but we also value the knowledge you will share with us. This interaction with you will take different forms, but our online forum and this blog will be major tools (do not hesitate, for instance, to contact us if you want to write a blogpost on the situation in your country or just share some reflections). We will also seize opportunities offered by face-to-face encounters to discuss on this topic with you (as we did already in Buenos Aires and as we will do again at the Cape Town symposium, in a satellite session co-organized with the World Bank).

This promises to be an exciting journey. We hope that you will be with us all the way long.

 
Note:
(1) We are very aware that some readers of this blog post are disappointed by the non-selection of their proposal. Proposals went through  a systematic appraisal system set up by the Alliance. Feel free to contact Mrs Maryam Bigdeli at the Alliance to know the reasons why your proposal has not been selected.


2 Commentaires

The Financial Access to Health Services Community of Practice through the lenses of an anthropologist

5/29/2014

1 Commentaire

 
PictureWorkshop in Bamako
Isabelle Lange
 
The  Harmonization for Health in Africa  Communities of Practice are today firmly installed in the global health landscape. The Financial Access to Health  Services  CoP (FAHS CoP) for instance gathers more than 700 experts committed to progress  towards universal health coverage through strategies such as user fee removal, health equity funds, health insurance…  In this blog, Isabelle Lange, medical anthropologist at the London School of Hygiene and Tropical Medicine and FEMHealth researcher reports findings of her qualitative research on the FAHS CoP itself. 

 “[The FAHS CoP online group] is effective for sharing information, for networking, and for the exchange of experiences…. It’s- it’s extraordinary…. First, through the community I discovered, I had the opportunity to exchange with a lot of people and now after the workshop, I think that they are friends… I will try to maintain these relationships despite…. Even if the relationship is there and exists you have to reinforce it and care for it.”
– Policy Maker, North Africa
 
More and more actors in the global health community are tapping into the growing range of resources to widen their networks and information bases. Communities of Practice (CoPs) fit into this trend, and as they become a more popular tool in today’s information management methods in global health, there is the sense that the utilization of the Internet and strong content can bridge individuals to create or strengthen a community.  A CoP then could provide resources for knowledge sharing and potentially also for informed health policy and systems change, breaking the traditional direction of north to south information flow and communication barriers across professional silos.  However, achieving this model can be a complex process dependant on many contextual variables; exploring the processes of a particular CoP can shed light on its contribution to health policy as a mechanism for knowledge exchange. This was one of my ‘assignments’ under the FEMHealth project.  
 
The CoP FAHS and the FEMHealth: three years of collaboration 
 
The FEMHealth project was a 3-year multi-disciplinary evaluation of maternal health user fee removal policies in Morocco, Mali, Burkina Faso and Benin. I carried out a semi-external view of FAHS CoP as a part of the health policy research. The health policy analysis aimed to understand the origin of the policies in these countries and why similar measures were taken around the same time period to reduce the financial burden of childbirth costs on women and their families.  There we explored whose voices were heard, which agendas were pushed and what evidence was influential in driving these strategies.  The FAHS CoP offered an arena to deepen that research by observing the current debates and actors, in addition to serving as its own study area on this mechanism as a
vehicle for knowledge sharing and transfer.  It also offered a channel to connect the FEMHealth researchers in with the wider community interested in their topic. As FEMHealth had supported the establishment of the CoP, it was also interested in understanding how well the CoP was meeting its goals of knowledge creation and exchange. In my capacity as anthropologist working on the health policy analysis research, I attended three FAHS CoP workshops (in Bamako 2011, Marrakech 2012 and Ouagadougou 2013) and alongside informal exchanges and observation of the content during those meetings, carried out in-depth interviews with the facilitators and about 25 participants – following up with a selection of them over the years to gain an idea of the value of the CoP within their professional and personal lives. 
 
CoP workshops

According to my informants, the CoP workshops cut across geographic, disciplinary and linguistic boundaries that frequently hamper knowledge exchange amongst different profiles of actors. The magic  formula for this was, according to participants: an appropriate participant body  – with engaged, knowledgeable actors there to learn and make a difference, not  just to collect per diems; dynamic, skilled facilitation; plenty of time for informal exchange (during coffee breaks or on field visits); quality simultaneous translation between French and English; pertinent technical content; and a format that allowed for questions, discussion, learning and problem-solving, not just presentations and “being spoken at.” 
 
A particular wish of participants was to have the beneficiary community voice present in the discussions, based on the feeling that they did not have space carved out to be legitimately heard in the usual pathways of decision-making. “I think that often we meet just amongst us, actors in the ministry of health, or those who implement the program, without taking many things into account because we can’t imagine the perspectives of the user or beneficiaries of the service”, stated a West African policy maker. “They have to be there to tell us ‘what you did like this, should have been done like this instead.”  This view was echoed in reference to other stakeholder groups, including health workers and researchers, underlining the absence of meaningful cross-silo exchanges in typical/existing professional structures. 

Importance of the online community

These workshops are an important part of the FAHS CoP identity – strengthening the membership and committing to action a core tenet of the knowledge-sharing mandate of CoPs. What was clear, however, was that the CoP workshops had another special component:  the online community that served as a base to these workshops.  This group offers a continuity and home to the technical content and face-to-face exchanges that similar conferences did not have. While many of the attendees at the workshops were not CoP members (at the time), the community thread ran through the conference and made its presence:
member participants were asked to summarize debates and presentations which were posted to the 700+ subscribers, who could then continue the discussion via email and feed back to the conference attendees with further thoughts and questions.  One workshop participant who is also a community member said, “I see these face-to-face meetings (as) very important. That's what feeds new community members and that feeds the online life to the next workshop. And so there are these two mechanisms – face-to-face - that are then a good trigger for online knowledge movement and communication and discussions.” 
    
In its own right, the online community served as a valuable link to work being done in health financing on a broader scale than many members were involved in their day-to-day professional lives.  Access to grey and academic literature, unpublished experiences, and especially the diverse opinions of fellow community
members on these pieces proved to be a reason why the online group was valued and, for some, ‘boosted confidence’ in their own capacity and was considered a unique contribution to the resources available in this field. 
  
Further reflections and future steps

The enactment of policy-relevant knowledge in more dynamic ways – through interactive meetings, continuous facilitation, editorials, and community building, among others – was seen to be a strong point of the community of practice model in providing both personal and professional benefits to members. But questions remain about strategies that can create a lasting impact in a world where many are over-worked and access to a surplus of material and resources can at times seem to be a burden rather than a benefit.  The CoP offers a reference point and an organizational component to information, people and networks, which, as one agency participant says, is “the key to the whole thing…. It’s knowledge dissemination, knowledge production, capacity building.” But, he continues, “a community of practice is not just there for the management, but to build something.” Over the past three years we have watched the FAHS CoP grow into a network of more than 700 individuals and as an organization have seen its presence at numerous conferences and affiliation with other professional bodies. Discussions around its ideal future structure emphasize its need to remain non-normative, independent and be member-driven,
not only member-responsive, in order to be able to contribute to shaping an environment that constructively and innovatively brings about positive policy advances through knowledge sharing. 
 
Read the accompanying policy brief for the facilitators’ perspectives on growing a CoP, and don’t hesitate to get in touch with any thoughts or ideas.  

1 Commentaire

Universal Health Coverage: a 12-country study to better understand the challenges of fragmentation among health financing schemes along the road to UHC

11/26/2013

1 Commentaire

 
Allison Kelley

In this blog post, Allison Kelley presents a descriptive research project being carried out by experts from two communities of practice – Financial access to health services and Performance-based financing - in twelve Francophone African countries.  One of the project’s innovations is its collaborative approach.

Universal health coverage (UHC) – is higher than ever on the agenda, both nationally and internationally. Presidents, key development partners, and even international NGOs are all pushing for UHC. What consensus! And yet – as is often the case – the devil is in the details – and in this case, in the many and ever expanding number of health financing schemes in African countries: user fees, budget allocation, funding inputs, community-based health financing schemes, fee exemptions for certain population groups, exemptions for the poorest, performance-based financing… Just to illustrate my point, one of our experts has already inventoried 29 different health financing schemes in Niger!

Such fragmentation in national health financing, without even mentioning the challenges of quality and human resources, can leave one feeling perplexed in the face of all the fervour around UHC.  How can the various pieces of the health financing puzzle be assembled to constitute a coherent picture at a national level? In many countries, there are a multitude of different actors involved in the planning and implementation of such health financing schemes (HFS), all with their own objectives. Many are unaware that they are in some way contributing to UHC in their country. They may also be lukewarm at the prospect of collaborating or being “rolled up” into some sort of larger scheme.

The diversity and confusion around various aspects related to the governance, objectives, intervention level, target groups, financing sources, available budgets, eligibility criteria, management and performance of these various HFS are such that no one today has the whole picture. And yet this picture would seem essential if a country truly wants to progress toward a more efficient and equitable national health financing system. It would also help to identify population groups that are less well covered, and those that may have double coverage (and those who stand to gain from such double coverage), inefficiencies, etc. I’d even suggest that having this full picture should be a prerequisite to defining and putting in place a national health financing strategy.

A multi-country study

Thanks to French Muskoka funding (with additional resources from Cordaid), experts from two CoPs – financial access to health services and performance based-financing – are carrying out a collaborative research project in 12 sub-Saharan Francophone African countries. Their goal is to map this tangle of HFS.  At the country level, we hope that this mapping exercise will create a clearer picture of the complexity of health financing schemes in-country. By comparing across the 12 countries we hope to be able to begin to trace some recurrent situations, or patterns, that we can interpret as favourable or unfavourable (using existing knowledge of health economics and political economy) toward expanding UHC.  

A collaborative process from A to Z

If this research is modest in terms of its scientific objectives (descriptive documentation only using existing secondary data and knowledge held by experts), it is more innovative from a methodological perspective: from its conception to its end, it is a collaborative process. 

Back in Spring 2012 (yes, it can take some time to turn an idea into a reality…), we organised a “virtual brainstorming” using the on-line discussion groups of two CoPs. We asked members to suggest priority research topics for a proposal to be submitted for French Muskoka funding (UNICEF WCARO). We then put the suggested topics to an electronic vote by members. The outcome was uncontested: the top priority topic was to better understand how to link up the ever-growing number of HFS at the national level in a coherent move toward UHC.

Since so many countries were interested in the topic, we opted for a more open research model that would capture a maximum number of experiences (rather than focus in on 1-2 countries): a sort of overview of what exists, not unlike the inventory carried out to prepare for the FAHS CoP’s first workshop in Bamako. We launched a call for individual experts to carry out the research at the country level. Because the Muskoka funding covered francophone countries (and only some of those at that), we ended up with candidates for 10 countries: Benin, Burkina Faso, Guinea, Ivory Coast, Mali, Niger, Central African Republic, Democratic Republic of the Congo, Senegal, Chad, and Togo. Our open model then led us to include two “non-Muskoka” countries, Burundi and Cameroon, thanks to Cordaid funding.

After signing the contract in Spring 2013, we were able to thus put the research team in place. A study guide was drawn up and shared with this team, and then improved through their comments and suggestions. A product of real joint collaboration!

What’s next

The research is finally underway. Researchers on the team are in continuous discussion on challenges, tips, and strategies for obtaining the financial data they need…

The results from this first phase of research – a mapping of HFS in 12 countries and a synthesis of the situation across these countries – will be presented at the March AfHEA conference in Nairobi shared more broadly by mid 2014.  This picture of almost a quarter of the countries in Africa should suggest some more general lessons and perhaps even some recommendations.

In early 2014, we will begin preparing the second phase of the research (to take place in 2014-15). Our intention is to develop a more in-depth questionnaire that we will test in at least one country. Phase 2 will thus take a “deep dive” in a number of countries (providing sufficient funding is available). We will attempt to document efficiency and equity losses due to overlapping and duplicative HFS and to identify areas for improvement. We expect that this second phase will produce concrete recommendations for each country studied in-depth.

This type of research project is definitely uncharted territory for the CoPs. Its the first time we have solicited member involvement for this sort of documentation. What we find especially interesting is getting involved in an area of research that is relatively less popular – multi-country studies and cross-country analysis. Between individual studies on health financing in a particular country and the tables WHO produces annually on international health spending, we think there is room!  And CoPs may just have a role to play, given their members span almost every country on the African continent. Still, our ability to succeed at such endeavours will depend on factors like our ability to coordinate amongst ourselves, and to help each other out where necessary. We certainly plan to document this original, collaborative research model along the way.

So stay tuned for preliminary results in early 2014. Here’s hoping that we can contribute to making more of the existing multiple and diverse HFS to expand UHC.


1 Commentaire

Universal Health Coverage in Africa, version 2.0

10/8/2013

0 Commentaires

 
By the Facilitation teams of the HHA Financing CoPS * 

In early September, CoP facilitators gathered at the Institute of Tropical Medicine in Antwerp to reflect on the journey of HHA CoPs so far and to brainstorm on future development.** In this blog, the facilitators of the 3 ‘Financing CoPs’ revisit the role the communities of practice can play in promoting the UHC agenda. They also need your contributions, by the way…

Universal health coverage (UHC), whose aim is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them, has recently risen to the top of the international health agenda. OK, so UHC may well be old wine in a new bottle, but if it helps to mobilize the troops, why not?

At this moment, the international community is still engaged in high-level negotiations on the exact make-up of post-MDG priorities. Judging by the actions,  reports and rhetoric at the latest General Assembly of the United Nations, it seems quite likely that UHC will be chosen as one of these priorities in 2015. Whatever decisions are eventually taken at the global level, access to quality health care is now high on the agenda of many governments from the South. Onward, thus, for universal health coverage in Africa too.

More attention to Universal Coverage from the CoPs

UHC has been a priority topic for HHA communities of practice since their inception, but now seems an opportune moment to spell out their contributions to the UHC agenda for the future. HHA set up CoPs to meet a pressing need: to consolidate good practices and tacit knowledge related to health care financing in Africa, both for the benefit of countries, but also among national and international experts. This consolidation could be measured by the number of experts who understand and use these best practices, both in terms of volume (inclusion of new experts and more sharing among different profiles) and in terms of quality (boosting individuals’ knowledge). The CoPs’ theory of change is that this consolidation takes place via the exchange, co-production, systematization and dissemination of knowledge on a set of technical practices. The fact that CoPs are growing steadily (the PBF CoP for example now has more 1,000 members) confirms that experts feel to the need be part of a network in order to better understand and stay on top of health financing issues.

The CoP contribution: the strength of the collaborative model

Our personal experience as facilitators has definitively convinced us that through their open, collaborative and facilitated way of functioning, CoPs are making a real contribution to the universal coverage agenda.

This contribution is happening in several ways.

First, CoPs facilitate the dissemination of knowledge generated by the numerous actors contributing to the global agenda of UHC, both from within and outside the CoPs. This sharing of information happens through our online platforms but also and perhaps more importantly, at the face-to-face events that we organize. An excellent example is the conference that the Financial Access to Health Services CoP will hold at the end of November in Ouagadougou: in partnership with researchers from the North and from Africa, a high quality conference is currently being prepared. An increasing number of actors are also inviting us to their own events or workshops so that we can share our observations and knowledge, but also help them more widely disseminate the results of their own activities (for example, the Financial Access CoP is a consultative member of the regional technical support committee for extending universal health coverage in UEMOA member states).

A second, and perhaps more original contribution is the collaborative dynamic of CoPs that allows us to “tap into” the hundreds of brains ‘connected’ to our platforms. In ICT terminology today this is called Model 2.0 or more specifically ‘crowdsourcing’. Through exchange and debate, CoP members can contribute to the identification of good practices (in terms of design and implementation of financing schemes in particular). Ensuring dynamic interaction is critical here, whether online or at a workshop, and the facilitators’ role is essential to distinguish between opinions and facts, between hypotheses and evidence.

Our many experts, by their very involvement ‘on the ground’ (in ministries, health facilities, support units, …) play a key role in enlightening the international community on feasibility, or the results observed in their country. Their proximity to operational implementation provides a ‘reality check’ for major international and national declarations. The lively online discussion in late 2012 on UHC was an excellent example of this feedback. At the end of the day, we are looking for results and not just lofty rhetoric. In Africa, these implementation issues remain a major bottleneck.

A multi-country study is launched

Beyond online discussions and this blog, certain CoPs are undertaking more ambitious projects. Two CoPs, Financial Access and PBF, have joined forces to conduct a descriptive exploratory study in 12 French-speaking African countries. The project has been made possible through French funding (Muskoka Fund), with additional support from the NGO Cordaid. The research will map the health financing schemes in place in these countries to better understand their complementarity, and also their overlap, in order to shed light what has become an opaque tangle of health financing. This multi-country research project is using an innovative collaborative model, and will be presented in the coming weeks on Health Financing in Africa.

Your participation

CoPs have proven that they have their place alongside traditional actors like Ministries of Health, international and bilateral agencies, NGOs and academic institutions. We are convinced that they can contribute in a very positive way to the universal coverage agenda, if they receive the support they deserve – from sponsors, but also from their members.

Last but not least, we want to make use of the opportunity to remind you that Health Financing in Africa is the blog of all members of ‘Financing CoPs’ of HHA. So if you want to submit a draft, don’t hesitate. In 2013 and 2014, we will be especially keen on receiving information on progress of UHC in your country, the challenges you face in your country, and the implementation process.

Notes:
(*)    CoP Financial Access to health services: Yamba Kafando, Allison Gamble Kelley, Isidore Sieleunou; CoP Performance-Based Financing: Nicolas de Borman, Serge Mayaka, Bruno Meessen, Emmanuel Ngabire; CoP Evidence Based Planning and Budgeting: Nadège Ade, Jérôme Pfaffman;
(**) More information on this meeting will be shared later.

0 Commentaires

Fee Exemption for Maternal Care in Sub-Saharan Africa: A Review of 11 Countries

9/30/2013

0 Commentaires

 
Bouchra Assarag (National School of Public Health, Rabat) interviews Fabienne Richard (Institute of Tropical Medicine, Antwerp) about a recent publication on fee exemption for maternal care.

In your article, you discuss the various policies of fee exemption for maternal care in 11 countries in Africa. What was your objective and what has been your strategy to collect information?

The article is based on a study we conducted in preparation for the meeting of the CoP financial access in Bamako in November 2011. The workshop focused on the exemption policy for maternal care. We did this preparatory work to give participants an overview of what is currently being done in various Anglophone and Francophone countries in terms of maternal health exemptions. The comparison of 11 countries in terms of coverage of care packages and financial mechanisms chosen by the countries has been a good starting point for the exchanges.

To gather the information, we first developed a grid (with one part focusing on the package of care covered by the policy and another part on the financing modalities) which we have tested in Burkina Faso. Once the grid was validated, we sent it to the 11 countries, more in particular to the person or department in charge of monitoring the exemption policy. In general, technicians of the Ministry of Health and/or the Ministry of Finance have completed the form. We sometimes used on-site researchers to validate or complete the form when some data were incomplete. We then tried to find the similarities and differences between countries.

What are the main findings of your analysis?

First, there is a wide variation in terms of covered services or types of cost covered by maternal health exemption policies. The minimum strategy, everywhere, was to make caesarian sections free, but the variations around this minimum are obviously important too: complications or not, normal births or not, post-abortion care or not, etc. The justification for a particular covered package in terms of health benefits or in terms of reduction of catastrophic expenditure is rarely made explicit in the formulation of a policy. Governments have not always allowed technicians the opportunity to make estimates and analyze the cost-effectiveness of a particular option.  Certain policies have been decided very quickly by the president in the context of an electoral campaign, which did not exactly facilitate their implementation.

Second, fee exemptions for maternal care are not the only targeted initiative to reduce financial barriers. Recent years have seen the blossoming of a number of initiatives to reduce the financial burden of certain population groups (pregnant women, children, elderly, poor, …) or patients with a certain disease (HIV, malaria, tuberculosis, …). This becomes very complex for caregivers to navigate, to know which paper to fill out in order to claim such free care. These initiatives, most of the time managed separately by different departments at the central level, are a burden to the hospital or district (specific monitoring tools, different reimbursement mechanisms, …). Some people will be doubly covered, like a child under five years old suffering from malaria, as many countries have programs for children under five as well as for malaria. But a 15 year old boy who is the victim of a traffic accident with his motorcycle in town will be far less lucky, as he doesn’t fit any category… but he needs surgery and this costs a lot… As for a forty year old woman who suffers from obstetric fistula following a difficult delivery, idem. The reply to her will be that it’s not on the list of emergency obstetric interventions.

In sum, even if fee exemption policies started from good intentions – to improve maternal health and reduce the financial burden on families, they may not achieve their goals because they have often been formulated too narrowly (selecting only caesarian section in the covered package) or because their implementation has not been adequately prepared.

A few years ago, you coordinated a collective work entitled “Reducing financial barriers to obstetric care in low-resource countries”. Which link do you see between this book and this new article? What is your personal analysis of the free maternal care policies, in terms of implementation, impact for women or children, or repercussions for health systems?

I would say not much has changed in terms of implementation of policies since writing our book: in almost all countries, there has been a gap between what was theoretically foreseen and what has actually been understood and implemented. Several factors can explain this: a fuzzy formulation of the policy (each has his own interpretation of the content of the package), a lack of monitoring of the policy and control measures to set things right if one has moved too far from the policy as it had been conceived, a lack of accompanying measures in terms of human and material resources.

My own analysis, based on observations in the field (as I’ve lived the life of frontline health staff in several African countries) is that human resources are vital for health systems and an essential element for  fee exemption policies to succeed. The state can inject millions in an exemption policy and announce that everything is free, but if in hospitals the nurses or other staff continue to accept informal payments, this will completely demolish the effect of the policy. Before launching such policies, we must think carefully on how to engage frontline staff so they can be policy stakeholders.

For the future, regarding the variety of targeted exemption policies I mentioned earlier, I really think we should join forces to achieve universal coverage. Many African groups have set up task-forces for health insurance, for example – which is positive – but sometimes with international partners without involving colleagues who manage targeted exemption policies. There is therefore still a lot of coordination work to do at the national level to synchronize efforts made by all. I’ve understood that the communities of practice received Muskoka funding from France to work on this, which is great news, as there’s plenty of work to do.

To conclude, will we see you at the conference of the Community of Practice in Ouagadougou in November?

Of course! I heard the program is of high quality. With many other researchers, including from Benin, Burkina Faso, Mali and Morocco, we will present the results of the FemHealth project, which focused on exemption policies in maternal health. I hope this conference will provide answers to the questions that remained unanswered after the Bamako workshop … as well as our review of 11 countries.

0 Commentaires

Alone we go faster, together we go further : communities of practice in support of making access to health care available to the poor?

6/13/2013

1 Commentaire

 
Photo
Fahdi Dkhimi, Maymouna Ba and Kadi Kadiatou

From 24 to 27 September 2012, Financial Access to Health Services Community of Practice organized, in collaboration with the Ministry of Health of Morocco and JLN network, a workshop in Marrakech. In this blogpost, three members of FA CoP get back on the event. This blog post was also published as an editorial in the journal “Global Health Promotion”.

While most everyone today agrees that countries should begin moving toward universal health coverage (UHC), how to practically implement this worthy ambition remains less than clear. One of the major challenges is to strengthen equity in health financing, and more precisely, to improve access to healthcare for the poor. For many countries, particularly low-income countries, the access of the poorest to good quality health care remains a distant dream. If the problem of ensuring adequate resources is important, the issue of knowledge management is also crucial. The implementation of many initiatives is hindered by inadequate knowledge sharing, which leads to repeating the same errors in different places. Hence the idea to create effective platforms for the production and sharing of knowledge, known as communities of practice.

The ‘Financial Access to Health Services’ Community of Practice (CoP FAHS) is one such innovative effort in Africa. Its objective is to promote the exchange and coordination among actors working on the issue of health financing and access to care. This CoP also aims to promote better consideration and use of evidence in the policy-making process (1). It largely operates through virtual interactions among its 400 members, but also through periodic face-to-face encounters at workshops organized around specific themes.

In September 2012, a workshop organized by the CoP FAHS was held in Marrakech, in collaboration with the Joint Learning Network (JLN) for Universal Health Coverage (funded by the Rockefeller Foundation, among others) and with a strong partnership and investment from the Ministry of Health of Morocco. The purpose of this meeting was to bring together a wide range of actors, from policy makers, to scholars and implementers, as well as members of the JLN network or the CoP, to address a key issue for achieving universal health coverage (UHC): health coverage for the poorest.

Ninety participants, including 11 country delegations took part in the meeting that had a number of innovative aspects: bilingual (French- English), working groups between peer countries, flexible organization of the 3 days, and content constantly being adapted to the needs of participants. But the most remarkable innovation was undoubtedly the workshop’s organization of a field visit - with strong support from the Ministry of Health of Morocco - to three sites where RAMED is being implemented, the Medical Assistance Program for Moroccan citizens identified as ‘poor’ or ‘vulnerable’. This “hands-on” aspect of the workshop has fueled in-depth exchanges and reflections on the challenges faced by African countries in the implementation of pro-poor strategies and medical assistance. It also gave the host country the opportunity to obtain the views of an expert panel on the RAMED, a program which began the crucial phase of nationwide scale-up in April 2012.

Beyond such positive feedback, the workshop’s theme - how to reach the poorest - is revealing of the magnitude of the task facing the CoP in the near future if it is to truly unleash effective knowledge sharing that informs and shapes the policy-making process (2). The key challenge remains its capacity to open up an area of health that has traditionally operated in a silo; one that has had great difficulty in incorporating multisectoral approaches. Even the process of selecting participants for this workshop demonstrated this problem: there was an overrepresentation of personnel of the ministries responsible for public health, whereas the organizations of civil society and the private sector, as well as other administrative services involved in reaching the poorest were virtually absent.

This lack of heterogeneity has introduced a bias in the technocratic thinking on the issue of access to care for the poorest. If the technical problems - the resolution of which is necessary but not sufficient in our opinion - have been widely discussed (identification of the poor, registration of beneficiaries, funding assistance, etc.), the presence of actors working in other spheres not related to health, especially the representatives of the poorest themselves, was missing in the debate, making it impossible to face up to structural issues in which inequalities in access to health care and in access to public resources find their roots.

The issue of access to care for the poorest is a major challenge for African health systems in their ambition to reach the UHC. Disparities in access and use are indeed a reflection of power dynamics that perpetuate structural inequalities of distribution of resources within a society and generate social determinism to access to care. These processes have been particularly highlighted by the work of the Commission on Social Determinants of Health, through its Social Exclusion Knowledge Network (SEKN) (3). This determinism plays full even when alternative mechanisms of financing health care are implemented - exemption, grant, gratuity, etc. - and partly explains the mixed results produced by these initiatives (4), see also Health Inc Research Project. A more structural analysis and a multi-sectoral approach is needed to understand all of the issues relating to access to health care for the poor and provide an effective solution.

Challenges that must be met successfully by the CoP will therefore be to become available to other sectors, other actors beyond technicians and experts in the field of health. It is on the basis of this capacity of the CoP to open up that it will be in a position to make a difference and provide opportunities for its members to leave the debates yet too restricted to technical issues, and which often cause erratic political processes (5).

References
1.     Meessen B, Kouanda S, Musango L, Richard F, Ridde V, Soucat A. Communities of practice: the missing link for knowledge management on implementation issues in low-income countries? Trop Med Int Health. 2011; 16(8): 1007–1014. doi:10.1111/j.1365-3156.2011.02794.x;
2.     Groves T. Development of health systems and universal coverage should be evidence based, says WHO. BMJ. 2012; 345 (2): e7530–e7530. doi:10.1136/bmj.e7530;
3.     Popay J. Understanding and tackling social exclusion. J Res Nurs. 2010; 15(4): 295–297. doi:10.1177/1744987110370529;
4.     Babajanian B, Hagen-Zanker J. Social protection and social exclusion: an analytical framework to assess the links. London, UK: ODI; October 2012: 12. Retrieved from http://www.odi.org.uk/publications/6889-social-protection-social-exclusion-design-analytical-framework;
5.     Mckee M, Balabanova D, Basu S, Ricciardi W, Stuckler D. Universal Health Coverage : A Quest for All Countries But under Threat in Some. Value in Health. 2012: 1–7. doi:10.1016/j.jval.2012.10.001;

1 Commentaire
<<Page précédente

    Our websites

    Photo
    Photo
    Photo

    We like them...

    SINA-Health
    International Health Policies
    CGD

    Archives

    Septembre 2019
    Juin 2019
    Avril 2019
    Mars 2019
    Mai 2018
    Avril 2018
    Mars 2018
    Février 2018
    Janvier 2018
    Décembre 2017
    Octobre 2017
    Septembre 2017
    Août 2017
    Juillet 2017
    Juin 2017
    Mai 2017
    Avril 2017
    Mars 2017
    Février 2017
    Janvier 2017
    Décembre 2016
    Novembre 2016
    Octobre 2016
    Septembre 2016
    Août 2016
    Juillet 2016
    Avril 2016
    Mars 2016
    Février 2016
    Janvier 2016
    Décembre 2015
    Novembre 2015
    Octobre 2015
    Septembre 2015
    Août 2015
    Juillet 2015
    Juin 2015
    Mai 2015
    Avril 2015
    Mars 2015
    Février 2015
    Janvier 2015
    Décembre 2014
    Octobre 2014
    Septembre 2014
    Juillet 2014
    Juin 2014
    Mai 2014
    Avril 2014
    Mars 2014
    Février 2014
    Janvier 2014
    Décembre 2013
    Novembre 2013
    Octobre 2013
    Septembre 2013
    Août 2013
    Juillet 2013
    Juin 2013
    Mai 2013
    Avril 2013
    Mars 2013
    Février 2013
    Janvier 2013
    Décembre 2012
    Novembre 2012
    Octobre 2012
    Septembre 2012
    Août 2012
    Juillet 2012
    Juin 2012
    Mai 2012
    Avril 2012
    Mars 2012
    Février 2012
    Janvier 2012
    Décembre 2011
    Novembre 2011
    Octobre 2011

    Tags

    Tout
    2012
    Accountability
    Aid
    Alex Ergo
    Assurance Maladie
    Bad
    Bamako Initiative
    Bénin
    Bruno Meessen
    Burkina Faso
    Burundi
    Civil Society
    Communauteacute-de-pratique
    Communauté De Pratique
    Community Of Practice
    Community Participation
    Conference
    Cop
    Course
    Couverture Universelle
    CSU
    Déclaration De Harare
    Divine Ikenwilo
    Dr Congo
    économie Politique
    élections
    équité
    Equity
    Fbp
    Financement Basé Sur Les Résultats
    Financement Public
    Fragilité
    Fragility
    Free Health Care
    Global Fund
    Global Health Governance
    Gratuité
    Gratuité
    Health Equity Fund
    Health Insurance
    ICT
    Identification Des Pauvres
    Isidore Sieleunou
    Jb Falisse
    Jurrien Toonen
    Kenya
    Knowledge-management
    Kouamé
    Leadership
    Mali
    Management
    Maroc
    Maternal And Child Health
    Médicaments
    Mise En Oeuvre
    Mutuelle
    National Health Accounts
    Ngo
    Niger
    Omd
    OMS
    Parlement
    Participation Communautaire
    Pba
    Pbf
    Plaidoyer
    Policy Process
    Politique
    Politique De Gratuité
    Politique De Gratuité
    Post Conflit
    Post-conflit
    Private Sector
    Processus Politique
    Qualité Des Soins
    Qualité Des Soins
    Quality Of Care
    Recherche
    Redevabilité
    Reform
    Réforme
    Research
    Results Based Financing
    Rwanda
    Santé Maternelle
    Secteur Privé
    Sénégal
    Société Civile
    Uganda
    Universal Health Coverage
    User Fee Removal
    Voeux 2012
    Voucher
    WHO

Powered by Create your own unique website with customizable templates.