Category: Policy Process

Scaling up and integrating your Results-Based Financing scheme: a progression in four phases

4/17/2017

Bruno Meessen

In a previous post, I have proposed to understand scaling up and integration of a results-based financing (RBF) scheme as a progression on five dimensions. In this second post, I present the second main lesson from the “Taking Results Based Financing from Scheme to System” research program: this progression, often, occurs in four phases.

There were several great things in the “Taking Results Based Financing from Scheme to System” implementation research program, but one I appreciated a lot was the opportunity to use our own experiential knowledge for developing and implementing the research: an interesting option, when you have in the research team, experts like Maryam Bigdeli, Por Ir, Joël-Arthur Kiendrébéogo, Eric Bigirimana or Isidore Sieleunou (among others), who have had hands-on experience on scaling up Results-Based Financing.

What I knew from my own policy involvement with RBF over the last 15 years in countries like Cambodia, Rwanda or Burundi is that scale up is a process going through several phases. At the launching workshop, I presented a four phase view to the rest of research team; we agreed that this was one of the things to investigate with the project.

So, what have learned on the process of scaling up and integration after field work in 11 countries?

Four phases of policy development

Thanks to the excellent work of the country teams, we have now quite a good understanding of how countries progress with their RBF schemes. From our sample of ten country reports, we see emerging pivotal points at which a RBF scheme gains a more advanced policy status. First, let’s review the four phases.

The generation phase refers to the movement of RBF from an initial idea to the establishment of one or more pilot projects demonstrating the feasibility of the idea. The end point or measure of success at this phase is a proof of concept, which is a significant progress on knowledge (‘it works in our context and we have learned how to do it’). If we take Cambodia as an example, this is a status that was already reached in 2001 for the New Deal (a ‘proto-PBF’) and in 2002, for the health equity fund. If we take Rwanda, we can probably say that PBF reached this status in 2003. All the schemes documented in our multi-country research went through this first pilot phase. It is important to note that a few got stuck at that stage and failed to move to the next one. This is for instance, the case of Chad.

The adoption phase refers to the transition from a pilot project to a program. By ‘program’, we mean a centralized organizational structure endowed and mandated by the national authorities to expand benefits of a specific strategy to a large population. For a RBF program to function, a unified, coherent and identifiable set of institutional arrangements has to be put in place. This includes among others, contracts, guidelines and management tools to administer the RBF scheme. If we refer to my previous blog on the five dimensions, this phase of ‘roll-out’ equates to significant progress on the two dimensions of population and service coverage. This progression is made possible thanks to significant progress on a the dimension of ‘knowledge’ as well (knowledge increases both in terms of number of trained experts at the national level and in the depth of their expertise).

By the end of this phase there is typically a central body, agency or task force, which manages a single national scheme (particularly key if there were several pilot experiments to harmonize). Yet the scheme is usually still a parallel entity since resources are generally not on-budget. By the time of our study, 8 of the 11 study countries had reached this phase. No surprise, this is a heavy phase, especially from an operational perspective. This is even more so in big countries like Cameroon and Tanzania.

The institutionalization phase refers to the movement of RBF from a program to national policy. The later will often be enabled by national resources and commitment from the Ministry of Finance. The RBF scheme becomes an integral part of the country’s health financing policy inscribed in national strategic documents and decrees, with a stated objective to cover the country as a whole. This phase is characterized by significant progress on the dimension of ‘health system integration’, which will lead the emergence of new knowledge to handle the related potentially complex issues (how to adapt to public finance procedures, how to contribute to the permanent improvement of quality of care…).

By the end of this phase, the RBF arrangement is a central part of provider payment mechanisms in the whole country and contributes in a coherent manner to main objectives of the Ministry of Health such as Universal Health Coverage.

Phase 3 is one full of complexity. The challenge is not so much operational anymore: it is about securing a smooth integration of the RBF scheme into the national system. You can’t do anymore “cut & paste” from another country. A few countries managed this phase very well – Burundi and Rwanda are certainly the best examples. The story in Armenia is interesting. Cambodia took more time, but eventually move to good ownership.

Our last phase or that of expansion refers to RBFs transition from a provider payment mechanism for health to a key principle informing the design and implementation of public policy in general, including in areas and sectors beyond health. In the health sector, PBF inspires further reforms, spurring other transformative processes (e.g. strategic purchasing). Outside the health sector, RBF principles including paying for results and provider autonomy are considered relevant for other public services. This lateral thinking has been enabled by the expansion of national level knowledge on PBF and confidence gained by experience in integrating it within the health system. This phase marks the progression on the ‘cross-sectoral diffusion’ dimension.

Very few countries have already this phase. Rwanda is one of them. Burundi is not far from it, but the political crisis of the last two years has undermined the progress.

Meanings of these four phases

Let’s remind that as any framework, this four phase view is a simplified representation of reality. It is there to focus our attention on a few key issues related to the dynamics of a scale up process. It is also a simplified representation of these dynamics. In reality, things will not be always clear-cut; there is continuity and possible overlaps. Still, we see quite some power in this view.

The four phase view has some analytical power. Zubin Shroff and I used the four phases to organize our analysis of enablers and barriers to scale-up and integration. It emerges from our analysis that these enablers and barriers are phase-specific. The main reason behind this is that scaling up and integrating a RBF scheme is about persuading a moving set of stakeholders. You will not move from phase 1 to phase 2 without convincing the Ministry of Health, one or two donors with deep pockets; you will not move from phase 2 to phase 3 without persuading national programs and the Ministry of Finance; you will not move from phase 3 to phase 4 without the highest national authority developing strong leadership towards societal reform.

For obtaining buy-in from these different stakeholders in the chain, different strategies will have to be adopted. Actually, even the identity of the actor championing the RBF scheme may have to change: for instance, our study shows that while international experts are often pivotal to succeed phase 1, technical leadership should be with senior cadres of the Ministry of Health from phase 2.

And what about prescriptive power? Is it required – in order to bring one’s RBF to scale – to follow the four phases, with due fidelity? Personally, I do not see the four phase view as a ‘universal law’ – there are probably countries, which merge phases 1 and 2 or phases 2 and 3. Still, one may wonder why so many countries do follow the same trajectory. There are probably several reasons for that. Let me point at one.

Much has been said about policy as a complex process which rarely develops in a linear way. This is very true; still, a policy is an intentional action : expect the policy entrepreneur and any other driving actor to act in a strategic way. Addressing challenges one by one, ‘converting’ stakeholders progressively, may facilitate success. Knowledge is also a key resource for actors championing the policy: if they learn that a sequence of actions worked in other countries, expect them to take inspiration from this lesson.

Directions for our community

Many of you work in countries which are still in an early phase of the scale up & integration of their PBF scheme. We hope that this multi-country research will help you to structure your action at country level. Please, refer to our cross-country policy brief for tips how to navigate the phases (or the related paper).

The study also shows possible directions for the whole community of actors committed to PBF. I see at least two. First, we should not sleep on our first successes: this is a long journey, setbacks are possible, and many challenges remain ahead. It is also our responsibility to consolidate the global momentum – our prime responsibility is to permanently improve our solution(s). In 2017, the PBF CoP will launch a series of working groups to work on the main weaknesses we do observe at country level. One has already been launched on verification; another one is about to start on family planning. More working groups will follow. We hope that many of you will support this dynamic. Second, we have also acknowledge that we belong a more global movement. PBF is not an end in itself : it is an entry point for consolidating a more comprehensive transformation of health systems to sustain progress towards UHC (do not miss this recent paper by WHO colleagues). As a community, we have to consolidate links with other groups. We will do that step by step. You may have noticed our emerging collaboration with WHO around strategic purchasing. Several members of our CoP will be next week at the meeting in Geneva. Stay tuned: more exciting developments are coming!

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

4/10/2017

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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.

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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Mapping fragmentation of health care financing in 12 Francophone African countries

9/17/2014

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

9/10/2014

2 Commentaires

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.

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

5/29/2014

1 Commentaire

Workshop 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.

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Results-Based Financing: going from scheme to system – a research program in the making

2/6/2014

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The Alliance for Health Policy & Systems Research, a global partnership hosted within WHO, is about to launch a new implementation research programme focused on results-based-financing (RBF). A few experts of the Performance Based Financing Community of Practice (CoP PBF) attended a preparatory meeting in Geneva on 23-24 January. In this blog post, they report on the two-day event.

The Alliance for Health Policy & Systems Research is known for its commitment to enhancing the dialogue between researchers and research users, policy makers in particular, in developing countries. As readers of this website know, the Harmonization for Health in Africa communities of practice fully embrace this agenda. Late December, several of us were contacted by Joe Kutzin (WHO, Geneva - Department of Health Systems Governance and Financing) and Nhan Tran (Alliance) to join them, together with other RBF and provider payment reform experts, for a consultation meeting to prepare a new call dedicated to implementation research on RBF. Olivier Basenya, Por Ir, Bruno Meessen and Laurent Musango made the trip to Geneva.

Participants were asked to assist the Alliance in identifying main implementation research questions related to the scale up and integration of RBF initiatives into national health systems and policies, and in identifying priority countries where such research would have a greater impact. After two days of intense interactive deliberations, it was decided that the research program will focus on the enabling factors and barriers for RBF (pilot) schemes to be scaled up and integrated into national health systems and policies, taking into account RBF design features and implementation process, health systems characteristics, and socio-economic and political context. We agreed that the importance (extent) of the scaling-up and integration would be assessed on several dimensions such as population and service coverage, institutionalization, financial integration in the public budget and so on. While some countries have been relatively successful in making progress on this multidimensional scale, others have been encountering quite serious obstacles in doing so.We are hopeful that this research program will bring interesting insights into how one needs to successfully navigate the policy process, combining efficiency with ownership and a sufficiently inclusive process, with the aim of strengthening health system and moving towards Universal Health Coverage (UHC). We know from previous meetings that national PBF champions are looking for guidance in this respect.

All participants made relevant contributions, with some as delicate as the tiny paper cranes produced by Professor Winnie Yip from Oxford University (picture illustrating this blog post). Others (like ourselves), conveyed their message in a more straightforward way. One of the things we emphasized was that it’s vital to ensure that the research process involves country health authorities in such a way that it allows them to reflect on the extent to which they have actually achieved health systems strengthening via the integration/scale up of their pilot schemes – a shift from scheme to system and policy.

Interestingly enough, the research program will not have a purely instrumental aim. Eligibility criteria will also allow applications by research teams willing to document processes which were wrong from the start, e.g. a pilot project with insufficient or no (government) ownership, or one that failed to be scaled up. It was suggested that the research areas should be a mixture of countries that have advanced in RBF implementation at national level, countries in pilot experiences phase and some others with a demand side component.

The planning of the Alliance is ambitious. We expect the call to come out soon, so keep an eye on their website (ourselves, we will of course inform CoP experts through our online forum). We hope that many of you will apply and submit letters of intention as this is a research program fully in line with priorities pursued by the PBF CoP.

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Scaling up and integrating your Results-Based Financing scheme: a progression in four phases

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

Mapping fragmentation of health care financing in 12 Francophone African countries

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

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

Results-Based Financing: going from scheme to system – a research program in the making

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Scaling up and integrating your Results-Based Financing scheme: a progression in four phases

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

Mapping fragmentation of health care financing in 12 Francophone African countries

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

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

Results-Based Financing: going from scheme to system – a research program in the making

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We like them...

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