Bruno Meessen 

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

Can one learn something from recent voluntary health insurance schemes?

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

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

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

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

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

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

Which coverage rate indicates success?

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

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

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

Ghana-France: 1-1

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

The link between UHC and governance

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

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

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

 

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

Isidore Sieleunou

In a recent Chatham House working group paper, Gorik Ooms (ITM) & Rachel Hammonds (ITM) explored whether a Global Fund for Health is a realistic option in the medium/long term, both from the perspective of so called “donor” and “partner” countries. Isidore Sieleunou had an interview with the first author. Gorik zooms in on some of the key messages, political trade-offs involved and implications.


Your paper comes timely, now that the ongoing (post-2015) debate on Sustainable Financing for Health is gaining momentum (See for example the theme of the next PMAC conference: “Global Health Post 2015: accelerating equity”). Could you summarize the paper’s key messages?

A Global Fund for Health would greatly improve the efficacy of international assistance for health, in particular because it would increase the predictability of assistance in the long run, which is essential for including international assistance in long term planning.

There are disadvantages for the countries receiving the assistance: a Global Fund for Health would be able to impose conditions in a way that a multitude of ‘donors’ cannot. But the advantages would outweigh the disadvantages. Compare it with the difference between charity and social protection: you don’t need to be a member of anything to receive charity, but you cannot rely on charity; to be included in a social protection scheme, you need to fulfill certain requirements, which can be inconvenient.        

You stress that the political interest for a Global Fund for Health may come from an unexpected corner -  more in particular, you see the issue of global warming as a good opportunity. Could you tell us why climate change could help countries rally behind a Global Fund for Health?

Climate change changes the nature of the relationship between countries. MDGs are about poverty reduction – that divides the world into donors and recipients. SDGs are about climate change, that affects all countries and requires efforts from all countries.  

In spite of the urgency of the climate challenge, the priority for developing countries is still development and poverty reduction. Especially climate change mitigation seems to be a far-fetched idea for most African leaders. Keeping in mind the relatively low priority of climate change for African leaders, what makes you think linking a Global Health fund with climate change could be a game changer in the political negotiations for the post-2015 era?

Precisely because the climate challenge is a higher priority for the wealthier countries, it puts poorer countries in a stronger bargaining position. They can say: “If you want shared responsibility for environmental sustainability, you will have to accept shared responsibility for social sustainability. Our constituencies will not accept any global deal on climate change that may have a negative impact on our economic growth if there is no compensation.”   

Do you think there are many takers in the Global South for such a worldwide social solidarity mechanism, with countries who will require money on a permanent basis, at least for some decades? Put differently, even if you allow for countries moving from recipient to donor status (or even for recipients putting a small amount of money in the Fund so that they are also ‘donors’), still countries will mainly be donors whereas others will mainly be recipients. How do you see this idea of permanent assistance fit with the ‘Africa rising’-narrative, now that more and more African countries say they want to get rid of development aid in the medium term, as they feel it’s patronizing and keeps them in a relationship of dependency?

I can easily understand the reluctance in the Global South. So far, international assistance has been like charity. If I were in the position of being reliant on charity, my first ambition would be to be in a position where I no longer need charity.

But my question to the leaders of the Global South would be: “How do you want to behave after you will have ended your reliance on aid? Will you behave as the wealthier countries do today, and hand out charity, or will you aim for something better, like global social protection?” I think the idea of global social protection fits very well with the African concept of Ubuntu.

The figures and estimates so far only reflect the first step of the transformation of global charity to global social protection. I think we should move very quickly to a regime under which all countries contribute progressively – the difference between both is illustrated by annex 1 and annex 2.    

In the current geopolitical environment, how attractive is a ‘Global Fund for Health’ for BRICS countries?

There is growing pressure in BRICS countries to increase social protection – and therefore to increase taxation needed to finance social protection. This is not easy, because of tax competition between countries: countries want to keep taxation low enough to attract investment. A global fund for health would not only organise transfers, it would set targets for domestic social protection levels, and that would mitigate tax competition, which is attractive for countries that would like to increase social protection levels but only if their economic ‘rivals’ do the same.

Furthermore, there are different ideas to finance a Global Fund for health. Simon Caney – professor at Oxford in Political Theory and Global Social Justice – proposes to distribute global emission rights through an auction mechanism. The countries or companies that are most able to ‘transform’ emission of greenhouse gasses into economic benefits would be willing to pay the highest price. The proceeds could finance a ‘green and social environment’ fund, including a global fund for health. This could be a lot more attractive for BRICS countries than the emission ceilings per country that are on the negotiation table now.

A number of donors and international stakeholders say the idea of a Global Fund for health remains a rather monopolistic approach. Competition of ideas, financing mechanisms and products often leads to better results, they say. What would you answer to them? Do you think a Global Fund for health might affect the quality of DAH in a negative way due to lack of competition ? Or is it the other way around?

Again, compare it with the difference between charity and social protection. Under charity, all rich people give as much as they want, when they want to, to whom they want to give. Some rich people can be generous, and may become less generous if they were asked or forced to pay more taxes to finance social protection. The ‘competition’ between Bill Gates, Warren Buffett and other wealthy people may have some advantages that may disappear. Social protection requires coordination: a central body that collects contributions and decides how to redistribute. It seems likely that some particular countries or some particular health issues would experience negative consequences, but overall, I would always prefer to be a member of a social protection scheme, over being the beneficiary of charity.         

You have been working on collective social responsibility, including this idea of a Global Fund for health, for a substantial part of your career. Are you optimistic about the prospects of worldwide solidarity, or social sustainability as you call it?

Yes. It will happen. But I don’t know when. I’ve become fairly pessimistic about the timing, but remain confident that it will happen. The alternative for a global social protection regime is increasing isolationism – every country trying to deal with its own problems on its own. There is no future for isolationism.  Ulrich Beck may sound naïve when he argues that climate change might save the world, but he has a point. Climate changes forces us to think beyond the nation state.     

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.

Allison Kelley

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

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

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

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

A multi-country study

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

A collaborative process from A to Z

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

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

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

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

What’s next

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

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

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

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

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

By the Facilitation teams of the HHA Financing CoPS * 

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

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

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

More attention to Universal Coverage from the CoPs

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

The CoP contribution: the strength of the collaborative model

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

This contribution is happening in several ways.

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

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

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

A multi-country study is launched

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

Your participation

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

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

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

 Manuela De Allegri and Isidore Sieleunou

Manuella De Allegri (University of Heidelberg) and Isidore Sieleunou were in Berlin last week at the GIC Forum on Health and Social Protection. They enjoyed this conference on Universal Health Coverage, but were really surprised by the fact that user fee removal was not discussed.  An oversight or a bias?

Last week, we had the opportunity to take part in a Forum organized by the German Cooperation on Social Health Protection, the title being Universal Health Coverage: From Promise to Practice. The Forum gathered international experts across the policy, the implementation, and the research arena. Health financing “veterans” of the level of David Evans, Joe Kutzin, and Tim Evans were invited to meet experts working for the German Cooperation, their policy and implementing partners across the world, and a selected number of researchers to discuss the challenge of moving countries towards universal health coverage (UHC) and possible strategies towards this end.

The forum provided the opportunity for extensive exchange, with provocative discussions and innovative thinking characterizing the two days spent in Bonn. We definitely took home a number of inspiring ideas. Notwithstanding the number of very interesting sessions, however, we were left to wonder how it was possible to spend two days discussing UHC and not once mention user fee abolition. The forum simply overlooked the experience of countries which have recently implemented user fee abolition as an initial step towards UHC. A wide range of strategies targeting all dimensions of UHC (population coverage, access, and financial protection) were discussed from efficient service purchasing to insurance systems, from cash transfers to vouchers … just no mention of user fee abolition.

In her key note speech, Dr. Speciosa Wandira-Kazibe, the former Vice President of Uganda, repeatedly stressed that UHC is all about responding to increasing demands for better health services, no matter what path towards the goal is chosen. She insisted on keeping open to all policy options, adjusting to the specific circumstances of each country.  Therefore, we later found the omission of user fee abolition somewhat surprising considering that the evidence on the impact of user fee abolition on improved access to health services and financial protection is by now quite substantial. While it is true that some countries might have rushed into user fee abolition without carefully preparing its implementation and might have therefore encountered problems to keep up the promise of improved access to quality services, other countries, such as Ghana or Burkina Faso, have successfully worked on the careful progressive implementation of user fee abolition (or reduction, as for Burkina Faso) for selected services and/or population groups. Interestingly, such countries have explicitly implemented user fee abolition/reduction with the intent of advancing population coverage on a limited spectrum of services, while preparing further-reaching health policy reforms aimed at advancing progress towards broader UHC goals.

We were left to wonder what could motivate a community that gathers to discuss strategies towards UHC to overlook user fee abolition. One thought that immediately comes to mind is that discussions on UHC are largely dominated by what sociologists would define as culturally dominant paradigms. The concept of cultural hegemony refers to how power is indirectly reflected in the ideas that we, as society, hold to be the most prominent. It is to say that the ideas of those who enjoy power in a community receive more attention and ultimately end up being the ideas that the collectivity holds to be true. User fee abolition has largely emerged as an endogenous movement within African states, one that only recently gained explicit support from international UN agencies and the World Bank. As such, one could see it as a movement that is simply not part of the dominant paradigm, as African states are not known to be the ones who hold the most power in the international arena. One could further postulate that the natural consequence is that user fee abolition is not deemed to be worth of the same attention as vouchers or conditional cash transfers, strategies to UHC largely supported by the exogenous international community. The discourse at the forum might have simply reflected the distribution of power at the global level, with some reforms endogenous to African states, such as user fee removal, receiving less attention than those widely promoted by the international community.

Moreover, the forum devoted ample space to discussions of the link between evidence and policy, paying specific attention to the function of knowledge brokerage. The community at the forum amply engaged in discussions on the role of the encounter between research and policy and on the need for knowledge brokers to facilitate this encounter, by enhancing two-way communication between the two. Still, we are left to wonder, how can effective knowledge brokerage take place in a context dominated by cultural hegemony? How do we even start discussing the path towards UHC in a fair way if the options we bring to the table are only the ones deemed worth of discussion within the framework of a dominant paradigm? Are we doing justice to UHC if we overlook a selected set of endogenous strategies?

We have no answer, but surely many questions to reflect upon as researchers committed to the production of the evidence for policy, beyond power relations and political concerns. Personally, we are looking forward to the conference organized by the Financial Access to Health Services Community of Practice in November in Ouagadougou. We look forward to the opportunity to discuss financial strategies to enhance access to maternal and neonatal health services, beyond dominant paradigms of what may be deemed and what may not be deemed worth our attention as we all strive together towards UHC.

Thierry van Bastelaer*

On May 23, 2013 a group of researchers affiliated with the Health Working Group of the Microinsurance Network were hosted by Consultative Group to Assist the Poor (CGAP) to share the results of their recent work on various facets of micro health insurance. In this blog (also published by the CGAP), Thierry van Bastelaer summarizes the highlights of this meeting, and reflects on the role of micro health insurance in the transition to universal health coverage.

The in-person and virtual audience engaged the presenters in a lively debate about a number of critical issues in the field, including why uptake of health insurance remains low, the relative importance of covering inpatient and outpatient care, the role of subsidies, the commercial sustainability of micro health insurance, the central importance of the quality of care made accessible through insurance, and the respective roles of the public and private sectors in providing insurance coverage to low-income families. 
 
That last point, in particular, was discussed at length based on an example from India. It appears that the large, publicly-funded RSBY scheme is crowding out Indian microinsurance providers when offered in the same markets. This observation led to the most fascinating question of the event (thank you, as always, Peter Wrede!): is there a future for micro health insurance?  Is it destined to go by the wayside as governments take on an increasingly larger share of the burden of providing coverage to their populations? Should it?

Like every other industry, microinsurance is—at least partially—concerned with its own survival. It can sometimes forget, however, that it owes its existence to failures in public (and sometimes private) insurance markets. As these failures are addressed and micro health insurance clients are increasingly covered by public insurance, there will come a point where all that’s left for the industry to do is acknowledge its role in this transition, and gracefully bow out. But we’re not there yet—for at least five reasons.

First, not all governments have access to resources like those of the Indian government, which is in essence financing the near-full cost of inpatient health insurance to more than 30 million of its Below Poverty Line (BPL) citizens.  Although that’s only about 10% of the total BPL population in India, the government appears committed and financially able to significantly expand that percentage over the coming years.  For most developing country governments, however, limited financial (and sometimes political) capital would make very difficult—at least in the short and medium term—to finance the cost of care for substantive numbers of people. While these governments are addressing these constraints, microinsurance can play a significant role in providing affordable solutions to low-income families, either by providing coverage in areas where governments have not yet reached, or by complementing basic public coverage.
 
Second, to the extent that micro health insurance can help build large risk pools, it paves the way for governments to channel their resources (in the form of premium or back-office subsidies) toward low-income families in these risk pools, faster and at potentially lower cost than through financing the full cost of care for these families.
 
Third, because of the critical need to reduce costs to levels that make their products affordable for low-income families, micro health insurers are continuously innovating to find cost-effective approaches to developing, distributing, and servicing health insurance products— innovations that governments intent on reaching the same populations may find useful to integrate in their insurance programs.
 
Fourth, while only governments have the ability to mobilize the resources necessary to finance large-scale coverage, there is no a priori reason (and little evidence) that they have a comparative advantage over the private sector when it comes to the two other segments of the health insurance value chain: underwriting and distribution.  In that respect, experiments in India and Nigeria with private underwriting and distribution of public insurance will soon provide critical information about how best to structure public-private partnerships along the health insurance value chain.

Finally, most governments committed to providing health coverage to their vulnerable populations will probably and rightly choose to start by offering a basic benefits package (accessible through public facilities) to the largest possible number of families. In this scenario, the most durable role for microinsurance may well be to offer a complementary add-on to public packages, either by providing access to benefits not included in these packages, or by offering options to seek basic or advanced care in private facilities. 

In any event, I expect that the microinsurance industry will, at some point in the not-too-distant future, realize that its growing irrelevance is the unmistakable mark of its success. In the meantime, micro health insurance can and should continue to provide health coverage options to those families that cannot afford to wait for the public option to help them meet the cost of urgent medical care.

* Thierry van Bastelaer is Principal Associate/Economist at Abt Associates in Bethesda, MD, where he provides leadership in addressing a broad set of issues involving livelihoods, health, and protection from financial risk. His work includes identifying regional trends in community-based health financing and other forms of community insurance, and providing innovative solutions to problems of financial risk protection.

Fahdi Dkhimi, Maymouna Ba and Kadi Kadiatou

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

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

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

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

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

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

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

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

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

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