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National Health Insurance in Low and Middle Income Countries: A suggestion for a component-based sequencing

4/10/2017

28 Commentaires

 
Erik Josephson
Many countries in sub-Saharan Africa are looking to set up national health insurance with the ambition of achieving universal coverage. In the classic approaches, launching national health insurance requires building a large infrastructure all at once. I argue that the components for national health insurance could be sequenced over time, and that small-scale strategic purchasing should be a starting point.

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It’s striking how much the Universal Health Coverage (UHC) agenda has been, from a financing perspective, conflated with contributory health insurance. Some of the reasons are understandable. Health in many low-income countries is currently financed through a combination of tax revenue, out of pocket expenditures and donors. There is a tension between the objective of mobilizing resources for health – which suggests to maintain user fees – and the objective of access to all – which suggests to remove user fees. Many countries don’t want to lose the direct revenue from the population – pre-payment is therefore the preferred option.

I’ve been reflecting these last few months about the challenge of sub-Saharan African countries engaged in the development of some sort of (contributory) national health insurance as a means to move towards UHC. My assessment is that developing a national health insurance scheme is a challenge, not necessarily because managing such a scheme is complicated and administratively burdensome (although that is certainly true) but because of the prevailing approaches to setting it up.


The classic sequencing approaches

I have observed three approaches for sequencing the setup of national health insurance: (i) big bang, which is to say covering the whole population and the whole country in one go, (ii) starting with a population segment, usually the formal sector, in some countries simultaneously with the poor (creating the “missing middle” problem), or (iii) starting with a certain level of health provision, e.g. hospital care. In several cases, a combination of these sequencing approaches has been used.

Ghana opted for big bang, albeit based on its history with decentralized district Community-Based Health Insurance. Kenya has had a mandatory insurance mechanism for several decades for hospital care for government employees, which is now slowly morphing into a contributory scheme for all levels of care and the whole population. Tanzania has an insurance fund which started with government employees which later evolved to incorporate other population groups. Some countries which have more recently started to consider introducing health insurance have received advice to make them contributory, and to start with the whole population at once, as in Liberia and Sierra Leone, or by population group with the informal sector gradually being targeted, as in Lesotho. The experiences of the frontrunner sub-Saharan African countries, e.g. Ghana and Kenya, over the course of their early years should give one pause in thinking about sequencing.

Indeed, what we see in the schemes already in place is a significant set of difficulties with respect to getting off the ground, such as with the key components of governance, the benefits package, quality of services and financial protection. In Kenya, settling on a design and navigating towards a consensus, or simply setting aside the concerns of some interest groups, took years. There is also evidence that weak governance of the Kenya National Health Insurance Fund since it started transitioning to its larger role has prompted calls for reform. In Ghana, where membership has stagnated at between 30% and 40% of the population for several years, both those who can afford it, and even those who are exempt from paying premiums, do not sign up to the National Health Insurance Scheme (NHIS) for a multitude of reasons. A government committee recently studied the main causes of the challenges facing the Ghana NHIS and cited among five main flaws that many citizens cannot afford the contribution, quality of care is low, and that many facilities are unable to provide all the required benefits. There is evidence suggesting that rather than improving access, being an NHIS adherent relegates people to second class service, and that the cash and carry system, out of frustration for which the NHIS was born, lives on.

In the classic sequencing approaches (big bang, population, geography, level of service delivery), even those which target population groups or service delivery levels gradually, the management and governance infrastructure must be built up front. This poses two challenges. First that significant resources must be allocated to setting up and running the entire administration of national health insurance mechanisms (requiring investment in registering enrollees, getting them to pay premiums in contributory mechanisms, identification of the poor, claims management, software development or acquisition, handling insurance funds, contracting providers, running accreditation, etc), from the beginning. Second that the human resource capacity must be present from the start to run the various units of the purchaser. These are complex systems each of which deserves focus to get right.

Given the very serious and costly problems which peer countries in sub-Saharan Africa have faced in setting up the administration of national health insurance mechanisms, those countries taking serious looks at launching health insurance schemes should think soberly about a different way of sequencing.

A proposal for a component-based sequencing

As against the classic sequencing approaches there could be one based on health financing and service delivery components. Components in this sense is intended to refer to the various sub-components within the three main health financing functions (revenue generation, pooling, purchasing), as well as those within service delivery. This approach would build the various components needed for a national scheme in a step-wise and cohesive manner, starting by focusing on improving the supply of health services and building the purchasing function, before providing the public with an explicit entitlement and expecting them to pay. There is no defined way of implementing the sequencing, but there would be appropriate sequences based on the context, and logical requirements (some components need to come before others).

An example of such a sequencing would be to start with a very restrained purchasing arrangement and benefits package, and then move, in an order to be established based on context, through granting provider autonomy to public facilities (where it doesn’t exist), having the government contribute tax revenue and channeling donor funds to strategic purchasing, adding value-added information in the documentation requested from providers for payment, creating a single government health purchasing entity, accrediting providers, incorporating private providers, enforcing contract terms with providers including contract termination where needed, carefully thinking about increasing the number of services reimbursed through fee-for-service and / or having a capitation payment for non-salary operational costs run through the purchasing entity (rather than from the Ministry of Finance or the Finance Unit of the Ministry of Health), creating equity-based exemptions, enforcing gatekeeping, putting rules in place against balance billing and so on.

Regardless of the exact ordering in this approach, in contributory mechanisms, revenue generation from the population would be left towards the end, therefore leaving aside the complexities attached to premium collection, and conferment of an explicit entitlement to later in the process, once the purchasing and supply-side service delivery structures are able to respond.

There is of course a ready-made restrained purchasing arrangement already widely in place in sub-Saharan Africa, namely supply-side performance-based financing (PBF). The structures, processes and human expertise have been developed over the last decade in a large number of countries, including those now considering contributory health insurance. The proposal therefore would be to start with this scaled-down mechanism for, and therefore manageable starting point for, strategic purchasing.

The order of the sequencing by component, as well as the timing, are certainly up for discussion and depend on context. However there are several benefits in this line of thinking. First, a gradual build up by component is a much more manageable process to putting in place national health insurance than is an all-at-once approach. The latter would be complex for anyone to manage, let alone countries which don’t have the required capacity in numbers or skills. Second, this approach provides a clear roadmap for policy-makers, allowing them to focus on the key elements to build quality services, strategically purchased. Third, the build up by component is a much less expensive path administratively than is the all-at-once approach. Fourth, difficulties encountered along the way in building up by component will have fewer and less widespread ramifications than in an all-at-once approach. Fifth, that building up by component can take as its starting point a pre-existing small-scale purchasing arrangement which is already widely present across sub-Saharan Africa. Sixth, that in this approach, the foundation for strategic purchasing is built at the start, preventing problems as seen in some countries in building strategic purchasing into insurance later on. Seventh, that in contributory mechanisms, leaving revenue generation from the population to later in the process gives the government more time to focus on improving both the purchasing function and the supply of health services, before adding into the mix the administratively expensive and complex, and politically charged, activities related to providing the population with an explicit entitlement, and asking them to pay for it. And eighth, this approach is inherently more equitable than the classic approaches, in the sense that in contributory mechanisms, without the need to collect premiums until later in the process, the system is not improved only for, or access only improved for, those who can afford the premiums.

I am humbly proposing this approach to help low and lower-middle income countries transition from passive to active purchasing more manageably. There are doubtless many issues to be thought through in this approach which I have not highlighted in this blogpost. I would be very happy to read reactions and suggestions for making this approach more robust.


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Voluntary health insurance: what the zombie tells us

6/17/2015

7 Commentaires

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

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

Can one learn something from recent voluntary health insurance schemes?

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

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

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

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

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

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

Which coverage rate indicates success?

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

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

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

Ghana-France: 1-1

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

The link between UHC and governance

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

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

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

 

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



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Mapping fragmentation of health care financing in 12 Francophone African countries

9/17/2014

4 Commentaires

 
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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).



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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.


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    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

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