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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

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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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Results Based Financing “the Messi way”

7/10/2014

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In this blogpost, Bruno Meessen (ITM, Antwerp) shares some of the key lessons he learned from the Argentinian Plan NACER. He compares this experience with the Performance Based Financing schemes that are being developed in Africa. Some interesting lessons...
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My first real encounter with the Plan NACER (now renamed “Programa SUMAR”, since the expansion of the target group and the benefit packages) (1) was in December 2013, at a donor meeting on RBF in Oslo. Martin Sabignoso, the Lionel Messi of Performance Based Financing (see picture), presented the Argentinian experience to us in a very convincing way. I was therefore happy to accept an invitation by the World Bank to attend its annual “Results and implementation workshop for RBF” (25 March – 1 April) in Buenos Aires. It was time to discover the experience in the country itself. Here are my own take home lessons (2).

Commonalities between SUMAR and PBF …

The Programa SUMAR and what we call Performance-Based Financing (PBF) in Africa, have many things in common. For a start, they both seem to work. In Buenos Aires, we had the chance to listen to Paul Gertler (Berkeley University). Paul is a big name in the research community: among many other things, he proved the impact of the Oportunidades scheme in Mexico and of PBF in Rwanda. He shared his findings on the impact of the Plan NACER on several key health outcomes. The figures are impressive: the Plan reduced the number of babies with a low birth weight, by increasing prenatal care use and quality; combined with better care for low birth weight babies, this led to a reduction in neonatal mortality among the scheme beneficiaries. One of the most interesting results is the reduction of the inequity in terms of health status across provinces: the poorest ones have caught up with the average in terms of infant mortality rates. The strategy is also very cost-effective.

Another similarity between NACER and PBF is the transformative power of the strategies – a feature which is growingly recognized as a key strength of such schemes. In Argentina, this could be seen at many levels. For instance, the program accelerated the adoption of ICT in the health system. Another nice example is the fact that NACER transformed the public health subsystem from one to which people were implicitly belonging (free health care) and implicitly covered (no list of health care services) into a system with formalization of the entitlement (people have to enroll in the program) and an explicit package of health services (Plan NACER Health Care Package). This has forced the public subsystem to collect names of people, which is seen as an important step in the development of a close relationship between the system and each eligible household. (3)

More fundamentally, it has demonstrated to the rest of the health administration the importance of focusing on results. During the field visit, I asked Claudio Scalamogna, general coordinator of the Programa SUMAR in the Province of Chaco, whether the new style of management brought by the Plan could one day penetrate other social sectors. He answered “This is my dream”.

A last similarity I want to highlight is the narrative used to present the scheme. When one listens to Martin, you get the impression you’re listening to a PBF champion. This is of course interesting, as both strategies developed in parallel and independently. I asked Martin how he explains this; his answer was straightforward: “Results Based Financing is about human beings, how human beings can improve their work, and how we, as policy makers, can empower the health workers towards a prioritized goal. Our assessment in Argentina was that in order to improve health of the under-covered population, we had to redesign incentives to health facilities, improve work conditions, give autonomy, provide opportunities for training and for greater participation in the health system. We think that is the secret and I am not surprised it applies to other countries as well”.

But the differences are even more interesting…

A first difference: Argentina is a federal state and the Programa SUMAR reflects this reality. The program rests on a two-tier contractual system: there’s one contract between the national level and each province and another one between the province and health facilities. The contract between the central government and the province has two components: 60% is paid on a capitation basis (in 2013, around 2.6 US$ per person who has registered for the SUMAR– but existing enrollees count only if they used at least one health service during the last 12 months), 40% is performance-based using tracer indicators (see below). Initially, the whole funding was coming from the national level (with money from a loan granted by the World Bank). But since 2009, the provinces have also been co-financing the program, up to 15% nowadays. This share is expected to grow further. Martin told us that an efficient trick to keep control over such a two-level system is to use the national funding to remunerate the provincial unit teams. This allows the central level to define the profiles of members of the provincial units and to have a say on recruitment by provincial units.

The national government maintains some key decision rights: it defines the list of health services that are covered under the program (the benefit package) and the categories of costs which can be covered at facility level with the revenue collected from the program. But the rest is under the control of the province. For instance, each province defines the fee to be paid to the health facility for each service. While the program´s rules stipulates that facilities are allowed to allocate to staff incentives up to 50% of the program revenue, it is up to  each province to decide whether that percentage will be 0 or 50. Of course, below the province, the health facilities are also granted key decision rights: thus the facility has the final decision on what to purchase (but with a variable degree of autonomy across provinces, as we could observe during our visit). We were told that in general, health facilities are prioritizing training opportunities, equipment and infrastructure improvements.

A second difference: more complex payment formulae

The National government puts the emphasis on 14 key interventions scientifically proven to have an impact on priority health problems. As quality is key for the effectiveness of these interventions, a lot of stress is put on fulfilling quality conditions. According to this principle, a province receives more resources as long as its performance is above defined targets. For example, if the province manages to give a first prenatal check-up before the 13th week to at least 29% of the eligible pregnant women, it will receive additional resources. The higher the percentage of women with early check-ups, the higher the retribution (It is a continuous payment function). Each tracer has a mandatory set of information regarding the quality of the health service to be reported for every case. For our example, the province must report – along with the name of the woman and her ID number – the  date of the first check-up, the week of gestation, the date of the last menstrual period, the probable date of birth and, of course, the name of the health facility that provided the health care.

The contract between the Province and the facilities is simpler. They are paid on a fee-for-service basis (a price per quantity, as in PBF systems). For a selected set of health services they have also an incentive to match some standards for quality. All of this is subject of ex post verification (see below). Additionally, some provinces are using higher prices for health services that fulfill the quality matrix. In this case, they are extending the sanction scheme post verification in order to penalize the cases that do not match these criteria.

I  discussed this approach with Gyuri Fritsche (World Bank). He reminded me that this approach – to pay for an output only if it has some key attributes of quality – was the initial strategy of the Belgian Technical Cooperation project in Rwanda (except that the BTC verified the fulfillment of quality attributes ex ante). This model had not been adopted for the scale up in Rwanda and elsewhere in Africa, as it was considered too difficult to bring to scale: collecting quantity and quality indicators separately was seen as much easier to implement – the former being collected monthly, the latter quarterly. The Argentinian system is indeed much more demanding in terms of routine data collection, but as we know, there is an ICT revolution going on. This is something we may have to reconsider in the future.

A third difference: allocation of the RBF revenue to individual bonuses is not the dominant model. Only seven out of twenty four provinces allow their facilities to pay incentives to the personnel. Martin told us that several reasons explain this heterogeneity. Some provinces do not want it for legal reasons, others because they don’t think direct incentives to personnel will bring better results; some also doubt they would be able to sustain a bonus scheme in the future. As a matter of fact, in the health centre we visited, the transfer received from SUMAR represented just 4% of the health centre wage bill. Not sure this would be enough to induce a dramatic change.

We were of course curious to know whether there was a difference in performance between the provinces which have allowed facilities to pay a bonus with the funding and those that haven’t. I asked the question to Paul and Martin. Paul explained that the outcome variables he used to prove the effectiveness of the NACER plan were very rare events; the sample sizes unfortunately did not allow to ascertain a possible positive contribution of individual bonuses. He is about to check this possible determinant with another data set. Martin’s assessment was that the main determinant of the surge in performance has been the  expansion of autonomy at facility level: to have resources and be free to allocate them. As he put it nicely: “Health facilities have set up collective management approaches. RBF represents a real change in the culture of the health system, including at health facility level. For the first time health staff are participating in allocation decisions. This is also incentivizing!” The staff of the health centre we visited gave us another (complementary) explanation: the economic crisis of 2001 was really terrible and the health system experienced a collapse. The reinjection of funds brought by the NACER plan and the fact that the health facility staff had decision rights was a relief and created a new dynamic.

A fourth difference: a more important role for external verification. In PBF schemes, external verification is mainly there as a mechanism to reassure sponsors about the reliability of the verification system; it is henceforth called ‘counter-verification’. The External Concurrent Audit in Argentina is more integrated in the general functioning of the RBF scheme. For instance, the information gathered by the external audit firm feeds into the supervision program of the internal auditors. The permanence of the external audit allows the internal audit to focus on supervision, coaching and problem solving. This is something very valuable as this allows the program supervisor not to be perceived as controller. In Argentina, the external audit’s decisions have biding authority: if a discrepancy from the rules is found, no interference by authorities is possible: the penalty will have to be paid. This external audit is costly, but interestingly enough, the fines it charges to health facilities are nearly covering the full cost of doing the external audit.

A fifth difference: the management of Programa SUMAR involves a lot of people. Olivier Basenya (Ministry of Health, Burundi) and I were a bit shocked by the numbers mentioned when we heard them for the first time in Oslo: 150 staff at the national office of the program and 700 for the whole country! Compare:  Burundi’s central level PBF team counts only 7 ministry of health staff and 3 staff affiliated to partners. Are too many people involved in SUMAR management?

As explained by Martin: “Our job is to develop the strategic planning, to provide support and to supervise the 7,000 health facilities involved in the program. We are also administrating the 24 legal performance contracts. Our team is therefore multidisciplinary: we have economists, physicians, lawyers, social psychologists, experts in communication, experts in information technology, accountants… Health progress is multi-causal, so you need to build multiple solutions, multi perspective solutions. We are always fine-tuning the strategy, trying to learn what the reality is saying to us. We are also very committed to training the provincial teams. SUMAR is also a program that integrates all other substantial programs. We are working with more than 30 health programs in our Ministry of Health”.

We also noticed  many medical doctors in the health center we visited (well, most were absent, but they were reported as members of the team). So, it is possible that the relatively large team of the SUMAR program partly reflects a context-specific reality, but we agree that some PBF national units in Africa could be strengthened.

A last difference:  the system is steered more dynamically

A big danger with a PBF system is self-satisfaction:  you set up the system and then you run it more or less in a routine way. At the workshop, I checked with Olivier Basenya about his main take home message, and he duly agreed: “the Argentinian national unit steers its RBF system in a more dynamic way than we do”.

To conclude

Argentina was a refreshing experience for many PBF experts. Let’s keep in mind that RBF is not about implementing a single standard model. Although there are principles and good practices, there might be even better practices out there that we still have to discover. We learned a lot from Argentina during our stay in the country. Conversely, the Argentinian team is also eager to learn from other country experiences, so don’t hesitate to invite Martin.

(1) In this text, I refer to “NACER” when I refer to the initial scheme. I use “SUMAR” when I refer to what is in place today.

(2) I express my sincere gratitude to the SUMAR team, and particularly Mrs Jesica Azar who kindly answered my numerous questions on the way to the health center.

(3) I find this idea interesting and could be considered in some African countries. Let’s illustrate the concept with the case of Burundi. Each child under 5 would still receive treatment for free, but the health centre would be reimbursed by the national PBF scheme only if the health centre can provide for each utilization by a child his ‘free health care’ number. The great benefit of such a model is that it incentivizes health facilities to enroll families in the program, a way to develop a stronger bond with them. I also imagine that our ICT/PBF colleagues could develop solutions to provide information on utilization by enrollees to health centres (lost in follow-up, etc) to improve continuity of care.


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Africa Health Forum: Investing, with the Private Sector, in Health in Africa

3/9/2014

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In this blog post, Serge Mayaka (Kinshasa School of Public Health and PhD student at the Université Catholique de Louvain) interviews Mrs Agnes Soucat, Director of the Human Development Department at the African Development Bank regarding an event that AfDB will jointly organize with the Jeune Afrique Group, in Geneva on 16 and 17 May 2014 (prior to the World Health Assembly). The Forum is designed as a platform bringing together key policy makers and heads of laboratories, financial institutions and all industries in the health sector.

What is the analysis underlying the organization of this conference?

Africa is undergoing profound changes, all of which have an impact on human capital development and on how various stakeholders from the public and private sectors consider investment in the health sector. Demography in Africa is characterized by a young and fast-growing population; this offers very dynamic growth prospects, provided there is judicious investment in human capital and a full leveraging of skills. Economically, African countries have been experiencing a growth rate of 5% on average for the past decade and continue to resist global crises. The private sector is more than ever present. On the technology side, the continent is experiencing the technological curve, with spectacular advances in information and communication technology. By 2025, mobile telephony network coverage will be almost universal. Politically, democracy is gaining ground in Africa, and governance standards continue to improve, thanks to the growing demand for citizen participation and accountability, which has encouraged democratic reforms and reduced conflict and civil wars. 

Aware of these changes, we believe that traditional investment in health is not an appropriate response. The challenges are different. The actors have changed. The technological means available have also changed. Healthcare supply and demand has evolved. Based on these facts, we conceived the Africa Health Forum as the first public-private forum on health economics in Africa. The Forum will acknowledge recent developments on the continent and give to the private sector a place equivalent to that of the public sector and foster interaction between the two. The Forum will highlight four main themes, in tune with the major changes the continent is undergoing, to guide investment in health: employment, governance, new technology and financing. 


Could you kindly illustrate what this new health investment model would mean, for instance, for an organization such as AfDB?

I think the multisector approach is a better option, because the continent's challenges go beyond the traditional health investment framework. In addition, the private and public sectors need to better develop their synergies for more efficient investments in the health sector. As part of its new human development strategy, AfDB will support investment in health through three thrusts: 

  1. Development of skills and technology to improve competitiveness and employment prospects. For instance, AfDB will support the development of the pharmaceutical sector on the continent, public-private partnerships and skills development to ensure the provision of quality care; 
  2. Promotion of efficiency and inclusion in healthcare service delivery. The objective is to optimize the use of financial resources and strengthen accountability and citizen participation in governance, provide equitable and better quality services attuned to the citizens' choices and contribute to the stability of societies characterized by openness; and 
  3. Establishment of inclusion-enhancing financial and social systems. 

 Based on your experience on the current dynamics in Africa, what do you see as the promising innovative solutions to enhance the development of the health sector in Africa?

African States and all public and private actors must mobilize to carry on the progress achieved but a new paradigm shift is needed to promote the development of the health sector. African states should mobilize more domestic resources to invest in health, and the current environment is favourable. The continent is indeed experiencing a remarkable growth rate making it possible to invest more national resources while putting in place policies that enhance equity and social justice. The fiscal space prospects linked with the exploitation of natural resources are also promising. It is also noteworthy that States which have made progress in terms of good governance, accountability and transparency in the use of resources for health are those with the best results in mortality reduction. African States should also intensify efforts to optimize the use of resources invested in health in sync with the Tunis Declaration of July 2012 on Value for Money, Sustainability and Accountability in the Health Sector.  They must create stronger incentives for evidence-based resource allocation and for activities with a high impact on health.

How is this different from what was already attempted in the past?

In the past, African countries relied heavily on foreign aid to finance health; balance of power must now be readjusted through the use of innovative financing mechanisms. Aid is on the decline due to the global financial crisis and donors' new priorities. The resulting financing gap must be bridged at the national level and States must use innovative ways to raise additional funds. For instance, several African countries are analysing sustainable financing options for HIV and malaria, and their implementation mechanisms. This includes in particular (Malaria Bonds), deductions from banking and airline ticket transactions, taxes on alcohol or cigarettes. Partnerships with the private sector are obviously also essential. 

Precisely: in terms of health financing, what according to you is the role of the industrial and commercial private sector in Africa?

The private sector is a key element in meeting the challenges currently facing the health sector in Africa. The private sector plays an important role in Africa at all levels of health service delivery and its increased engagement could help to improve the quality and accessibility of services, accountability, create jobs and promote robust economic growth on the continent. The private sector has a key role to play to trump the ongoing technological revolution which offers new options for health service management, financing and delivery.

In this case, a new vision for the health sector would be necessary... 

Indeed, the health sector is a productive sector that can provide about 1.5 million jobs for African youths by 2020 and contribute to the economic growth of the continent. For example, the development of the pharmaceutical industry and an increase in the demand for medicines create opportunities for research and development, manufacturing, sale and distribution of drugs. Outside the commercial sphere, there are several opportunities as well for the development of social entrepreneurship in the sector.

Can you give us more information on the format of the Africa Health Forum? How will the momentum be maintained after Geneva?

The Africa Health Forum is intended for policy makers in Africa, both from the public and private sectors. It aims to provide African policy-makers with the information and tools they need to make informed decisions that will help them better invest in the health sector, throughout their country or region.

Therefore, the Forum is designed as a networking platform. 'B2B' (Business to Business) meetings will enable the participants to meet confidentially in dedicated lounges. An exhibition space will also be made available to companies wishing to present their activities to participants. Hence, the Forum will make it possible to engage in discussions that could culminate in partnerships.

In addition, AfDB, as is already the case, will continue its regular dialogue with governments driving through ideas, best practices and solutions presented at the Forum.  AfDB will also listen to the public and private sector representatives to explore opportunities for collaboration and support for their initiatives. Lastly, the Africa Health Forum is designed as a regular come-together; the second edition of the Forum will provide an update on progress achieved and maintain contact with the participants of the first edition. 

For more information, please visit the forum website. 

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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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Interview with Agostino Paganini (2/2): "the Bamako Initiative died a long time ago"

4/22/2013

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The second part of our interview with Dr. Agostino Paganini brings us to the evolution of the Bamako Initiative over time and its political feature. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years now.  He was the manager of the Bamako Initiative (BI) Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the BI. In the 1990s’ and 2000s’, he continued to work with UNICEF as a Team Leader for Health in Emergencies and as a country director in Somalia. He has also done senior consultancy work with the World Bank and advises the director of CUAMM (Doctors With Africa).

In retrospect, some people say the Bamako agenda has rarely been properly implemented. In a post on this blog and in an article, Valery Ridde says we me be better abolishing the Bamako Initiative (it is of course a provocation). How do you view the implementation of the Bamako principles until now?

Absolutely. I think this initiative died a long time ago. I think some of the principles are still incredibly valid and some of the problems it was trying to address also still exist. The problem of public accountability and people participation in the management of their health system should be have been better addressed with more democracy but still, it is left unattended in many African countries. The problem of out-of-pocket expenditures with no rules is also still extremely valid. We can call it Bamako Initiative or we can call it the way we want, it does not really matter: some of the problems which the Bamako was trying to address are still there and some of the experiences and principles (some have been applied and some have been badly applied) are still very relevant. But as an initiative, no, I do not think there is such thing as a Bamako Initiative alive at the moment. At least I have not seen anything. 

Would you agree with Susan Rifkin who says that the Bamako Initiative has widened the horizons of community participation? Do you see the current shift from community participation to community accountability as another widening?

Let's be clear, community accountability is accountability towards the community. The difference now is that communities become shareholders. Before they were paying under the table, now they pay and they can ask, what have you done with the money, why have you not done this or that? This is the difference between a vague participatory process and being represented and part of the management of the health unit. And this is something we still need to work on. People have no voice and no exit in low-income countries, except to go to the private sector, but this is not for the poor.

In her recent interview on this blog, Sassy Molyneux insists that we must “carefully consider remuneration and other forms of incentives for community representatives, the challenges of asymmetries between health staff and community representatives in resources and power, and the importance of building trustful relationships”. To me, this sounds a bit like considering the local politics of health. It always struck me how little attention seems to be paid to politics in the BI. We are in a sort of political process, right?

It is political. And not understanding that it is political is the biggest mistake you could do. I think that within the public health community we are sometimes very naïve. We think about supervision and training as the keys to everything but health is political. This is why the US has its health system and this is why Scandinavians have a different health system. Science is science but how science is available as well as the quality of and equity in access to care are political issues. We have to accept it is a though road to get to high quality equitable health care and we are not there yet. There still is a huge asymmetry between the health staff and the people and it is a sign that democracy is not there yet. We need to start from this problem. What I have seen with the Bamako Initiative is a deeply political, not a strictly technical, issue. But of course, people use things and declarations in different ways and they have used this initiative according to their own interests and point of view.

Twenty five years have passed. You have an extensive experience of primary health care in low income countries. According to you, what will be the keys for primary health care in the next 25 years?

What I see coming is more privatisation and more urbanisation. People seem to find in urban areas and even in slums opportunities they do not have in their rural areas. Some countries are growing and establishing health insurance which is an excellent thing I think. At the end of my time working on the Bamako Initiative, we were working on two things (there were two teams). One was community-based monitoring, because data are power. The other was local insurance. Health insurance is a key issue but it is difficult to establish. In many case they start at the national level; yet, in Europe local solidarity mechanisms were the initial insurances.

We need to work on public accountability and equity. These are the two key areas. Are we going in this direction? I am not sure. I think in some countries we are, but in a majority of other countries the private sector is growing as people have more resources and the public sector remains under-financed. What is more, this public sector is very inefficient unless there is public accountability. This is the mixed picture I have. On one side, they are countries progressing, doing very going things. Take for instance the experience of Rwanda with community-based health insurance (French: mutuelles de santé) and new staff remuneration policy. But on the other side, there are many others I think are not going in the same direction.

Any questions I have not asked and you would have liked me to ask or any conclusion you would like to make?

Not really, for me, as I said, it was a fascinating experience. I realised it was also a fascinating debate. Some of the issues are, as I said, very political and some are extremely relevant now. We have to address the relation between the patient, the client and the provider. The current debate of performance-based financing, which is linking financing not to the drugs but to the results, is also extremely interesting. Of course, it will not solve all the problems. I think we should be able to see what the good experiences were in the past and move on, adding on new experiences and new things. Basic public accountability and the role of people is extremely important, good governance of health facilities is very important but result-based financing of health facilities is also very promising if we combine it with other things we have learned. We should not move from fashion to fashion but take the past into account, understand what we have learned and build on it.


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Newton’s apple

3/26/2012

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Bruno Meessen

It is time to realize that institutional arrangements and the incentives they set up are key determinants of the performance of health systems in poor countries as well. Thanks to the development of health insurance and Performance Based Financing, there is growing awareness of this reality in Africa. In this blog, Bruno Meessen highlights the specific contribution of PBF.

Recently, I have posted a blog reminding us that Africa is also a field of political stakes (in French only). I shared the view that health economists working in the continent too often overlook this reality.

Very often, I am puzzled by something that seems even more striking. Reading certain authors, listening to some commentators, chatting with peer scientists – no weblinks provided for these ! ;-) – it is perfectly possible to design health policies in Africa (and in low-income countries in general, the literature being pretty homogenous) without paying attention to the incentives established by institutional arrangements and contracts underlying these policies.(1) These experts’ vision is not on the fringe: it has dominated thinking on health systems over the last few decades and remains the default mentality of many actors engaged in strengthening health systems in Africa.

Yet, the fact that “incentives matter” (especially for health care providers) keeps many experts busy everywhere else in the world. Over the last two or three decades, health systems in rich countries have experienced broad and deep reforms of their institutional arrangements, governance structures and provider payment mechanisms in particular. The dynamic is also fairly strong in middle-income countries, especially in ex-socialist countries.

A few weeks ago, I was at a meeting on provider payment mechanisms organized by the "Joint Learning Network for Universal Health Coverage". We heard fascinating presentations, among others on Kyrgyzstan and Estonia… and of course shared the analysis that provider payment mechanisms will be a key issue in countries’ progress towards universal health coverage.

A question overlooked by researchers and international agencies active in Africa

The situation is different as far as poor countries are concerned. Anyone reviewing the literature dedicated to their health systems (even the papers authored by economists) would find very few empirical and theoretical documents dealing explicitly with the question of how institutional arrangements shape the health system, how they shape incentives or even on the specific topic of provider payment mechanisms.(2) Over the last twenty years, other topics – such as financial access (as far economists are concerned) – have captured most of the attention.

One could debate the reasons explaining such low attention by researchers. De facto, they seem to discard the many lessons produced by different major contributions in economics, which, over the last few decades, have established institutional arrangements as the main determinant of efficiency in human interactions.(3)

In terms of impact on policies, this lack of attention is not neutral. The implicit recommendation to African countries is that they can proceed towards universal coverage on the basis of the existing model: a national health service characterized by the State fulfilling all the roles: owner, employer, supplier, purchaser, regulator, administrator… A system in which health facilities are public administrations receiving their resources through line item budgets, often even “in kind”. It is precisely this status quo that PBF champions are challenging.

The contribution of PBF

PBF has shortcomings. Perhaps it benefits somehow from being "trendy" and yes, there is a strong favorable wind in terms of donor resources. The model can certainly be improved, and will have to be revised, as health challenges evolve, actors adapt and unintended negative consequences increase. This is but the normal evolution of any modern health system.

 PBF has at least one great merit: it has brought the issue of incentives to the center of the debate on African health systems.(4) One concrete example is the spotlight now being put on previously neglected issues, such as the need to split functions in a health system. It has also breathed new life into forgotten topics (such as decentralization and making health facilities more autonomous). More fundamentally though, it has shaken up reflections on provider payment mechanisms, witnessed in the first papers presenting PBF pilot experiences, recent works produced by members of the PBF CoP, and on a nearly daily basis in discussions on our discussion group.(5)

A fad or… Newton’s apple ?

The stake for African health systems is not whether to implement PBF or not. It is to learn to look at health systems as complex institutional arrangements that set incentives for the actors involved in those systems. It is to realize that when incentives are not aligned to health system’s goals, they can (and should) be modified.

Taking this perspective is recognizing that incentives are an undeniable part of our relationships to our fellow men, just as gravity is an unquestionable dynamic in our relationship to objects. It is said that Newton developed his theory of gravity after an apple fell on his head. Perhaps another such apple has fallen upon African health systems?

Translation: Bruno Meessen & Allison Kelley

Notes :
(1) Be careful, incentives do not necessarily mean « bonus » or « financial gain ». An incentive is a gain in terms of wellbeing which one can appropriate by adopting a certain behavior. A student in theology has an incentive to succeed his exams: by obtaining his degree, he will gain access to career opportunities and personal accomplishment in his priesthood within his Church.
(2) Of course, one way or another, the question of incentives underlies most studies on health systems challenges. We recommend these stakes be made more explicit. A few researchers active in Africa have taken up the challenge. Of particular note is Kenneth Leonard and Natasha Palmer.
(3) The list of economists active in this field is very long. If one just reviews the list of the laureates of the “Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel”, with Herbert Simon, Ronald Coase, Douglass North, Georges Akerlof, Michael Spence, Joseph Stiglitz, Elinor Ostrom and Oliver Williamson, one covers the spectrum pretty well. 
(4) Let’s be honest. The other dynamic that has helped to bring incentives under the spotlight is the rise of health insurance. But so far, the discussion has been mostly limited to institutional arrangements dealing with risk pooling (cf. the literature on community based health insurance), and as far provider payment mechanisms are concerned, on the pros and cons of fee for service versus capitation.
(5) The discussion 3-4 weeks ago was about how to remunerate providers providing services to malnourished children and patients with chronic illnesses. It has involved experts based in the following countries: the Netherlands, Congo, the US, Chad, Central African Republic, Belgium, Cameroon, Cambodia, and Rwanda.
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Value for Money in the health sector: not just a donor agenda

12/15/2011

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Bruno Meessen

In this blog, Bruno Meessen argues that the ‘value for money’ agenda is also an African one. A key test for Performance-Based Aid schemes will be the extent to which they consolidate reform initiatives already taken at country level.

Over the last 15 days, we have had the opportunity to read two interesting contributions on the progressive shift of the aid agenda towards ‘results for money’.

Let’s start with the most recent one.  On the Broker Online blog, Marcus Leroy, a former technical assistant for the Belgian Cooperation, criticizes the increasing dominance of the “results for money” agenda (and more specifically performance-based aid) in the aid industry.

Leroy’s review of the ‘value for money’ agenda is rich. He first discusses it at a conceptual level and then at the operational level. In this post, I would like to focus on a few points related to the facts (the philosophical and moral issues he identifies I will leave for another blog…). And obviously, given my background, I will stick to the health sector.

First of all, let me be clear that I agree with Mr Leroy on this important point: performance-based aid (PBA) is not without risks. He identifies several of them, some of which were discussed at our last Incentives for Health Provider Performance Network event in May at CERDI in Clermont-Ferrand, France. Presentations there gave us a better understanding of the proposals on the table: some are well advanced (such as the GAVI one), some - maybe the most radical ones -, such as COD Aid or TrAid+ are still under development. All were really interesting. However, the half-day of exchanges also made us realize that PBA will not be the magic bullet that (part of) the aid sector has been in search of for decades.  

Facing the unknown, it’s only natural to feel some fear. PBA is no exception - many of us have fears about the approach. My main concern is that donors will opt for narrow targets within one sector, resulting in few positive spill-over effects across sectors and the whole local society. Worse, an incentive scheme focusing on just one health problem could have major distortionary effects for the sector overall. I understand that experts in the USA and in Europe are working hard on these issues at this very moment. We heard at a recent aid agency meeting that DfID is making progress in the development of its performance-based aid instrument. We sincerely wish them success.

Three points of criticism

I do not, of course, agree with everything Leroy states in his piece. More specifically, as far the health sector is concerned, I would like to raise three key issues.

First, I think it’s important to make the distinction between performance-based aid and performance-based financing (PBF) at the country level. PBA entails a contract between a donor and a recipient country. PBF, on the other hand, is about institutional arrangements (and involves thus much more than just a contract!) mainly between a central government (for example the Ministry of Health) and health care facilities. Some commentators confound the two strategies. That’s a mistake.

I would encourage Mr Leroy to read up on recent PBF experiences in the health sector. He will notice that a whole community of experts and actors is increasingly involved in this approach, and that PBF typically entails broad institutional changes, with a view to the long term. We invite him to visit the health sector in Rwanda for example, or Burundi, where he will see first hand how transformative PBF can be. He will also see how PBF can put pressure on donors to harmonize their interventions and can increase government ownership (if donors are willing to comply with the Paris Declaration, which is of course not always the case).

Secondly, let’s not discard the New Public Management agenda so easily (as Leroy seems to do). Many low-income countries do need such reforms for their public sector. As with any reformist agenda, mistakes have certainly been made and will be made again. But it is not because, let’s say, the financial incentive scheme set up by Sarkozy for the French police is controversial that  health care facilities in sub-Saharan Africa shouldn’t be remunerated according to the services (both in terms of quantity and quality) they provide to society. Evidence (or opinions) gathered in other sectors, in other times and in totally different settings do not naturally hold in other circumstances.

This brings me straight to my third point of criticism – which I see as most important. It is a huge mistake to see the agenda of ‘results for money’ as being predominantly driven by the North and the “usual donor suspects”. Just read the viewpoint of Donald Kaberuka, President of the African Development Bank and former Minister of Finance of Rwanda, published two weeks ago in The Lancet. Some of you may not know Mr Kaberuka; he is arguably one of the most active and committed reformers in Africa today. The major progress achieved in Rwanda over the last decade is not only a story of political leadership at the highest level, but also one of getting reforms ‘technically’ right. While Paul Kagame has been a key figure, a lot of the progress in Rwanda has come about because of the commitment of a whole generation of dedicated and visionary Rwandan technicians. Some are still in the country; others, like Mr. Kaberuka, are now sharing their experience and vision at the regional level.

As you might expect from somebody in his position, Mr. Kaberuka’s paper is short and focused. The main message is straightforward: thanks to economic growth, African countries can expect to have more and more domestic resources in the near future. What they need most now is accountability. While the author displays a broad understanding of the concept (including democracy) in his paper, he also emphasizes what accountability means from a public finance perspective: public money bringing more benefits to citizens. Mr. Kaberuka’s track record and his paper give a clear indication of the policy he has in mind, and PBF is part of the package.

Is this just the vision of a successful ex-Minister of Finance, one might wonder? At a workshop organized by the World Bank in Limbe (Cameroun) two weeks ago on PBF in the health sector, I took note – again – of how important this agenda of greater accountability is for many senior African officials and technicians (although the sample was of course biased). My point is this - the accountability agenda formulated so eloquently by Mr. Kaberuka and others is not something imposed from outside.

A double proposal

In conclusion, PBA is high on the agenda in the North, and will likely remain so in the coming years. Some Western aid experts are voicing concerns. In his post, Mr. Leroy rightly raises the question of the ‘agency’ of the party under contract. Will PBA fully respect the sovereignty of the recipient country, or will it be yet another tool for donors to impose their own objectives and preferences? I may be naïve, but my guess is that the donors testing out this strategy will aim for a fair and balanced negotiation with the recipient country. But will this be enough to diminish the deep distrust that some stakeholders have developed toward bilateral aid agencies?

I have two constructive proposals for donors working with PBA.

First, it is critical to get recipient countries’ perspective on PBA. It would be great if the consultation was transparent (maybe it is in some places, but I am not aware of it). Why not organize some rounds of structured discussions with a few parliaments in the South? As we are reminded by Kaberuka and Leroy, accountability should be directed first of all towards citizens of the recipient countries. I hope that PBA can perform better than existing aid instruments in this respect.

If such a stakeholder consultation process is not possible, another option would be to suggest the PBA strategy first to Rwanda. After the summit in Busan, we know that this would be a sure way to get the perspective of African leaders on this aid instrument (at least of the most vocal one). 

For our part, we will ensure that the Financing Health in Africa blog serves as a platform for African experts to share their views and observations on PBA; communities of practice can  play a role in this drive for more accountability.

The second proposal is to correctly identify what success looks like under PBA contracts. I would argue that the main test will not be whether PBA manages to curb the HIV/AIDS epidemic or maternal mortality (although these would be great feats of course). The real test for PBA will be whether such schemes consolidate country-owned agendas for accountability or whether they undermine them. In this respect, the way PBA relates to different reforms enhancing accountability in the health sector (see the list proposed by Donald Kaberuka) will be the key.

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