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

4/10/2017

Erik Josephson

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

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

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

The classic sequencing approaches

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

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

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

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

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

A proposal for a component-based sequencing

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

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

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

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

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

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

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28 Commentaires

Juliette Alenda link

4/11/2017 09:10:31 pm

Dear Erik,

Thank you very much for this blog and for these inspiring ideas. I will react on some points, to try to support this vision.

This specific assessment it true, already have evidences, but still isn’t considered in the construction of UHCs. Urgency is highlighted, it is necessary to cover the whole population. But we cannot hope to federate people around a system if the supply of health always has strong lacks, if they have to travel long distances to get treatment, and so on. The supply of health must keep pace with the development of coverage (Boussery, Campos, Criel, 2012, Awomo Ndongo, 2015). Ghana is a good illustration of that, Rwanda as well. The obligation is in place in the country, the very strong will of the government to cover the whole population leads to tensions at the local level. The quality of health centers and the presence of human resources varies from one district to another, and membership loyalty to mutuals is challenging. The emphasis has been placed on health centers in the context of decentralization, which results in a large increase in patients in these centers and can cause delays in their care. As a result, priority is sometimes given to patients who have the ability to pay directly. Finally, repayment processes are cumbersome (Mwedzi, 2013).

The fact, as you say, that this approach can be a clear roadmap for policy-makers and that this would be less expensive could perhaps convince them, or at least support the idea of a better coordination that is fundamental between the actors of the health system and between the various levels of the health pyramid, but which is still sorely lacking. But it will be necessary to take into account, within each country, the relations of power between the actors, between the various organs of the health sector, to adapt well to the various contexts. In Senegal, for example, the system lacks a systemic approach (Alenda-Demoutiez, 2016), while the strategy you are proposing could provide more coherence. I will take a concrete example to illustrate the real needs of a stronger foundation of health care supply before establishing coverage and of a better coordination. In the speech to the nation of April 2006, President Abdoulaye Wade declared his willingness to put in place the Sesame plan for the elderly. On September 1, 2006, the plan was created, enabling all people aged 60 and over who have no medical coverage to access health services, and it’s free of charge (regardless of the level of the health pyramid) for consultations, hospitalization, essential medicines, biological analyzes and radiography. However, according to a study carried out in 2010 by the Commission for the Supervision and Regulation of Social Security Institutions, stock-outs raise many problems, leading to the non-application of fees, consultations and care medication. Chronic diseases are important (such as diabetes), and are not supported by the plan. Financial problems and lack of resources arise, due to insufficient prior studies. The provisional budget of 500 million FCFA has been exceeded, pre-financing of hospitals is not enough, eligibility criteria are not fixed, encouraging a two-tier system for more affluent people or pensioners which already receive a pension. Support for the plan is cumbersome. The supply of gerontological care (equipment, staff, training, etc.) is insufficient. Lack of communication with the population, structures, and local authorities leads to the non-respect of certain procedures.

On the idea that we focus too much on user fees, I would like to add two points of perspective. Even with an improved health care and institutional support, the issue remains important. I will take the example of a system I know again, that of Senegal. The principle is to set up a mutual by each local collectivity, which subsidies from the State, all supported by USAID. Contributions are thus thought to be "affordable" for individuals. Except that, not only it is still unaffordable for many people, but you have to add the co-payment. The way to design user fees is therefore very important. Potential members, in a situation of great precariousness, cannot project themselves in the future, they have a greater preference for the present insofar as joining the mutual means paying twice for the acts, even if the amount charged to them is less important than with the direct payment (Defourny, Failon, 2011).

This is in linked with the debate on free access. A study by Robert and Ridde (2013) summarized the papers produced by global health actors. Just over half of them are in favor of free access, but if it is selective (pregnant women, primary care, indigents, etc.). There is a growing consensus on the inefficiency and inequity of free health care to fund a health system (McKinnon, Harper, Kaufman, 2015). So much so that in 2013, two researchers, Manuella De Allegri and Isidore Sieleunou, attending the Forum organized by the German Cooperation

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Juliette Alenda

4/11/2017 09:12:35 pm

on Social Protection of Health, were surprised that the exemption was not discussed at all. The interview is available on our blog (http://www.healthfinancingafrica.org/home/the-way-to-universal-health-coverage-ideas-beyond-the-dominant-paradigm). The decompartmentalization of the various programs would also play an important role in this context, in order to establish bridges between the various budgets and between the various health insurance schemes. In the context of the UHC, the opportunity could be to move from a "logic of targeting indigents to a logic of targeting a basic package for all", in order to achieve universal coverage that highlights the fight for the right to access care (Ciss et al., 2013).
Finally, I would like to add one last point, in relation to one of the projects we have just started on the Collectivity platform on petty corruption in health facilities in Africa. All these difficulties which lead, in Ghana, as in Senegal with the Sesame or in Rwanda, on a two-tier health system, must surely contribute to this phenomenon.

References (sorry, a lot are in French)

ALENDA-DEMOUTIEZ (2016), Les mutuelles dans l’extension de la couverture maladie au Sénégal. Une lecture par les conventions et l’économie sociale et solidaire, thèse de doctorat, Clersé, Université Lille 1.
AWOMO NDONGO J.C. (2015), "Émergence des mutuelles de santé au Cameroun", Recma, n°336,
pp 23-35.
BOUSSERY G., CAMPOS V., CRIEL B. (2012), Harmonisation for Health in Africa (HHA). Service
Delivery of High Impact Interventions: a study conducted in four West African countries, ITG Press,
Studies in Health Services Organization & Policy, n°30.
CISS M., VINARD P., DIOP K., TAVERNE B. (2013), Evaluation des coûts et des mécanismes de
financement pour renforcer l’accès aux soins de qualité pour les PVVIH, Rapport final de mission
n°13|N|101, CNLS.
DEFOURNY J., DEVELTERE P. (1999), "Origines et contours de l'économie sociale au Nord et au
Sud". In DEFOURNY J., DEVELTERE P., FONTENEAU B. (éd) : L'économie sociale au Nord et au Sud, De Boeck, Paris et Bruxelles, pp 25-50.
MCKINNON B, HARPER S., KAUFMAN J. S. (2015), "Who benefits from removing user fees for
facility-based delivery services ? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone", Social Science and Medicine, vol. 135, pp 117-123.
MWEDZI C. (2013), Les mutuelles de santé au Rwanda [En ligne] Enda, IWPAR, URL :
http://www.iwpar.org/id-15-rwanda-les-mutuelles-de-sante.html
ROBERT E., RIDDE V. (2013), "Global health actors no longer in favor of user fees: a documentary study", Global Health, vol. 9, n°29.

I hope this little contribution will help. Thank you again,

Juliette

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Godelieve van Heteren link

4/12/2017 10:55:52 am

PS to my earlier comment: It seems to me that starting a comprehensive approach in terms of system elements, but at a subnational geographical/population scale is the best way forward... In fact, in PBF this is already the best practice. Testing the waters first.

Godelieve van Heteren link

4/12/2017 10:51:47 am

Dear Erik,

Am very happy with your blog which corresponds beautifully to what a number of PBF implementers have been saying for some time now. Transforming health systems is a step by step process (big bangs rarely work) and the PBF building blocks fit the UHC agenda nicely, and involve the same basic conditions (decentralizing power, increasing provider autonomy, engaging in strategic purchasing and developing the proper checks and balances/governance structures) which are prerequisite for building a proper health insurance system. So PBF and insurance modalities coincide. Key is a careful process. If you look at how in Europe health insurance came about, it was never through a big bang, always through the kinds of processes you describe. In short: fully support your suggestions... let's work on them some more....

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Erik

4/12/2017 04:42:04 pm

Hi Godelieve, thank you for your comments. I think you are right about PBF implementers expressing these views. Despite that, I would posit that PBF in many countries is currently not viewed in the light I describe in the blog, and would go further to suggest that there is a risk that PBF will shut up shop in the years to come in many places for lack of country ownership (and funding). If you accept that assessment, I wonder whether you might elaborate as to what in your mind are the different steps which PBF designers and implementers need to take to alter the course?

Many thanks

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Mary Dain

4/12/2017 05:38:05 pm

Great post and what you are saying absolutely makes sense, and the proposal makes clear that there is no "one size fits all" way to impose health insurance in a resource limited setting, which is why the stepwise approach is required. One question along the lines of what Juliette says above concerns that intended order of the sequencing approach you outline. The strength of the approach is very clear, but if I were an administrator in the health financing division in an MOH attempting to implement UHC, I wouldn't know where to begin. More importantly, it seems likely to me that this process could be drawn out, as resources might render each step few and far between on the slow climb to coverage, and therefore I would love to know what you think about what will happen if one step is implemented and then nothing else for a year, or two steps and then two years. Given that most countries are de facto taking baby steps towards covering their populations anyway, what can be done in terms of governance to allow for the slow rate of progress? Would it make sense to do certain things first, as a result of these likely delays? Some commentary on ideal order would strengthen your outline of the intended approach.

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Mark Malema

4/13/2017 08:20:59 am

The post makes alot of sense to me regarding the approach to national health insurance. Countries like Malawi where majority non poor in informal sector who enjoys free services contributed by the few through payroll and general taxes skews the health financing system in that the few contributes despite consumption is by all based on their health care needs. A properly designed insurance that captures the informal non poor with effective identification and targeting mechanisms could be step wise approach apart from from the building capacity, purchasing function, autonomy and decentralization of district health system as suggested in the blog.

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Gowokani Chijere Chirwa

4/18/2017 03:38:03 pm

Mark

I think by now we should have been at a different stage all together. We should have implemented something. I wonder why for decades we are still at the point where we are still saying; " we will start". When will it be?

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Kai Straehler-Pohl link

4/25/2017 10:45:05 am

Dear Erik, dear Mark,

As everyone else commenting, I am very supportive of the ideas you, Erik, develop in this post. Like Mark, I am supporting the Malawi MOH on health financing reforms. The MOH recently requested an assessment of the feasibility and appropriateness of NHI in Malawi. I believe that our case is rather typical, both in the genesis of the interest in NHI, and the findings and recommendations of the assessment and can therefore be helpful in the ongoing discussion.

Genesis of interest: The Malawi health system is underfunded with per capita expenditure of around US$40 and donor dependency above 60%. NHI was identified as a potential way to address the funding problem, alongside other ideas such as earmarking taxes and levies. So the key driver of the discussion was revenue generation. Good publicity from other countries (Rwanda, Ghana, Tanzania,…) made it sound like a good idea and politics took note, and the issue made it into the election manifesto of the now governing party and a performance agreement between the Minister of Health and the President.

Results of the appropriateness and feasibility assessment: An analysis of the Malawi Revenue Authority showed that it is not possible to directly identify the “able-to-pay” for NHI contributions. At the same time, the poverty targeting mechanisms of the social protection programmes are not sufficient (accuracy and reach) to allow reliable identification of the “too-poor-to-pay”, exempt them from user-fees that would need to be introduced (Malawi never introduced user-fees) and subsidize their NHI contributions. In consequence, it was suggested to focus on implementing the purchasing function of NHI, while leaving the revenue collection for later when the Revenue Authority and targeting mechanisms have developed sufficient capacities.

So Malawi is at the stage, where the technical discussions have started focusing on purchasing and related efficiency gains. Two donor-supported PBF pilots (RBF-GER/NOR and PBI-USA) as well as a purchasing agreement between the Government and faith-based facilities, labelled Service Level Agreements, provide a base from which to start.

At the same time, the proposed solutions do not directly address the initial objective of Malawi policy makers: revenue generation. The long-term nature, the technical complexity and the jargon involved in making the case for the reforms (fiscal space through efficiency gains, purchaser-provider split,…) create challenges in connecting the technical and the political discourse of reforms. We do not only face a technical challenge but also a political economy and change management challenge and I suspect that many of you face the same issue. So we (policy makers and their technical advisors) need to handle these challenges to Keep the policy space open for Sound reforms. Agyepong and Adej provide a great example of how politics influenced the development of Ghana’s NHIS (Health Policy Plan (2008) 23 (2): 150-160).

Back on the technical side, and taking up Erik’s reply to Godelieve, I am also curious to see how flexible the PBF pilots will be to become a Government/NHI led active purchasing mechanism as long as they are donor financed and also serve - at least partially - a vertical agenda (e.g. the RBF pilot is for MNH).

Looking Forward to Hearing from others how they manage the two challenges, technical and change Management in their contexts.

[The NHI appropriateness and feasibility assessment was carried commissioned by the Malawi MOH, carried out by Oxford Policy Management and financially supported by GIZ in the context of P4H Network support.]

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Dimitri Renmans

4/13/2017 03:13:46 pm

Dear Erik,

Thank you very much for this interesting blogpost.

I just returned from Uganda, where the MoH is envisaging to use the implementation of PBF as a stepping stone towards NHIS. In the PNFP sector, the PBF funds are seen as a subsidization of the user-fees: the facilities reduce the user-fees and the purchaser (in this case the BTC project) pays the difference.

Therefore, this might be an interesting case to follow. However, the PBF projects in Uganda are still funded by donors and although the MoH is very keen on continuing this way of financing, the big question remains whether they will have the funds to do so.

The key question not only for PBF but also for advancing towards an NHIS remains whether there will be enough political will to free up the necessary funds or even increase the taxes.

This proposal of PBF as a stepping-stone towards NHIS is also very interesting in the light of the ideological (non-)debate surrounding PBF which we elaborated a bit on in a recent publication: PBF as the epitome of neo-liberal policies to privatize the health sector, or as a way to encapsulate the private sector and move towards a government-led NHIS.

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Shripal Doshi link

4/18/2017 03:37:30 pm

This is a very relevant blog post and is aligned with the approach that is being taken in The Bahamas, which I am supporting. The launch of National Health Insurance is being done with a specific Primary Care Benefits package.

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Nicolas de Borman link

4/18/2017 11:07:05 pm

Hi Erik,

Thanks for this truly great blog. I am also convinced about incremental approaches to UHC and the rationale of focusing first on strategic purchasing. Unfortunately most health financing strategies in low income economies propose big bangs. As a result, countries struggle with the implementation of UHC policies.

I think that the starting points should be an explicit benefit package and aligning the package with the existing provider payment mix. This offers something to build a dialogue on. Once that is done, the priority can be shifted to improving purchasing (more pooling, more output based, regular update of the benefit package, ..).

I think PBF systems have had often very positive effects in the sense that they have opened the door to data driven financing. However, I think we have not sufficiently succeeded in anchoring PBF in a broader dialogue on purchasing. Not that many countries implementing PBF have explicit benefit package and a clear description of how that package is supposed to be purchased (and how PBF contributes to the provider payment mix). Countries manage strategic purchasing "inside PBF", but do not manage the broader provider payment mix. I think it is still time for countries to build on PBF to enhance their strategic purchasing capability. For example, I think that "PBF teams" can evolve from "PBF purchasing" to the management of "mixed provider payment systems".

You might like that slide that comes from the software industry and that describes how to build complex systems:
https://docs.google.com/presentation/d/1FCHvWV9kdtEe9CM1sCyCBO9W_u95Hmrwaq5AISgqzEM/edit?usp=sharing

Thanks for this

Nicolas de Borman

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LLUIS VINYALS TORRES

4/19/2017 06:01:56 am

Dear Erik,

Thanks for sharing your ideas. Making us think about where to start and review success and failures is refreshing and badly needed.

I particularly like your idea to leave the collection part to the end. I strongly agree with it. With this is mind, the "insurance scheme setting" gives space to a discussion more focus on strategic purchasing for UHC, which is what matters at the end of the day.
In demanding context as the ones that you are referring to, I would also support your idea of baby-steps. I would even try to move towards a more explicit purchasing of donors and Government money using very simple allocation formulas.

Back in 1995, three donors in Mozambique pooled resources to pay the recurrent costs of district hospitals through a formula that combined performance (discharges, deliveries, consultations), poverty, need (population) and higher costs (distance from provincial capital) indicators to allocate the envelopes. It was a transparent, perhaps rudimentary, but cheap way to start rewarding performance. Later, many other donors and finally the Government joined the scheme.

I am sharing this example as a way to start moving towards active purchasing in places with little contracting/ monitoring capacities.

I hope that this helps a bit,

Best,

Lluis

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Prof Robert Basaza

4/21/2017 06:05:26 pm

I thank Erik for this forum, Prof Bruno Meseen from ITG for this invitation and all the contributors.I have just opened this blog.I will in the next couple of days write on the need of policy analysis stream (Kingdon theory) with a focus on the politics(the absolute commitment by the the Head of State, need to put all the actors on Board (public education especially with a focus on leaders at national and local governments), capacity building in the country(central and local governments) and need of a policy champion. Best

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Joseph Adrien Emmanuel Demes

4/29/2017 06:58:04 pm

Hi! all,
The debate is very interesting. What I would like to stress is the aspect of equity. For me equity means everyone should get access to the health system according to their needs and not according to their capacity to pay. Imagine you have a car accident and they get you to the emergency room at the hospital and once you arrive there they ask you to pay to get access to the service. If you do not have any money with you, you could die. Imagine a poor women who need a surgery to save her life and she has no money for the operation. There is lot of example that show us that the existing system in the developing country, like Haiti or in Africa is inadequate and do not facilitate proper access and quality care. What I would like to say is that we need a prepaid system where the people or the NGOs or the Government can mobilize money and resources in advance so that when someone is sick that person could get access to the health care system. Universal Health Coverage is for the whole population. I acknowledge that it is very challenging but there are developing countries like Costa Rica who has made a tremendous step toward Universal Health Coverage. It should be based on the notion of solidarity: solidarity of the reach towards the poor, solidarity of the workers towards the non workers or unemployed, solidarity of the young towards the elders, and also the last but not the least solidarity of the rich countries towards the poor countries. If only the rich countries could give 1 or 2% of their GDP to the poor countries so that the poorest countries in the world, like Haiti, could make a step toward universal coverage that could be great.

Now beyond the aspect of resources mobilization, we need to take into account the political aspect so that we could have the leadership of the government and the main stakeholders mobilized around that vision of universal health coverage (UHC). The context is very important as this could influence the process toward UHC in each country.

The actors at different level of the health system is paramount: local, governmental, non governmental, international actors, NGOs etc.. We need to take into account those actors, their interests, their values, their resources and realize a stakeholder analysis in order to assess the situation and move in a coordinated way toward UHC.

Beyond the context, the actors, we need to work also on the content of the UHC, the package, the services for UHC. Besides the process of implementation is very important as sometimes we know what to do but we fail to implement it the correct way. That means not only we need to assess, diagnose the current situation to identify the best strategy according to the context. We also need to find the best way to implement the strategy according to the context and the actors.

It is a very complex adventure and there is no magic bullet: each country needs to find its way towards universal health coverage. We also need a process to need from each other success, failures and difficulties so that we avoid the same mistakes again and again.

I will stop here. I write too much. I hope you understand my points. It is a real pleasure to contribute to this great adventure towards a National Health Insurance System.

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Meena Jadhav

4/30/2017 08:04:35 am

Hi Eric,

First, congratulations on this very important endeavor and innovative approach. My comments to your post are more of my reflection on India’s pathway to UHC and the debates on National Health Insurance Scheme.

Indian healthcare is characterized by an underfunded public health sector, over-reliance on a largely unregulated private sector, high out-of-pocket expenses, and a relatively insignificant health insurance sector. The recently launched National Health Policy 2017 explicitly outlines the policy direction regarding financing of health care in India. India’s health financing would continue to be financed through taxes with an interim focus on strategic purchasing of healthcare from the private sector and in the longer term free provisioning of drugs and diagnostics for secondary and tertiary care at public health facilities.

Contributory national health insurance schemes in India are challenging to implement for reasons including a largely informal workforce, high incidence of poverty, low awareness and understanding of health insurance, and administrative challenges in collecting premiums. The RSBY – Rashtriya Swasthya Bima Yojana (Hindi) often referred as India’s National Health Insurance Scheme for the poor is, in fact, the single largest experiment in strategic purchasing of healthcare from the private sector. The scheme involves central and state governments contributing to the premiums for the enrolled households and a token enrollment fee from the household, and operationalized through health insurance companies. The scheme covers hospitalization cost up to Rs.30,000 per household that includes most of the secondary level care through empanelled hospitals both public and private, but mostly private. Though a comprehensive nationally representative evaluation of the RSBY is not available, several studies have found over-treatment, unnecessary hospitalizations (as only the hospitalization was covered), unnecessary surgeries, and in some cases outright fraud involving private health facilities. Therefore, strategic purchasing of healthcare from the private sector to be optimally effective may require provider regulation, robust health data systems, and quality evaluations, and most importantly an empowered patient. Most of these capacities are still in nascent stage and would take some time to reach the lower tiers of the health system. This not only involves building information systems at the local level but also a transitional shift in the work culture of the health staff involved.

Recent initiatives by the Indian government in the spirit of the national health policy involving strategic purchasing are the mandatory prescription of generic medicines by doctors wherever possible, and government funded retail outlets for generic medicines under the brand name of Jan Aushadhi (translation – Peoples medicine). This appears to be a right decision considering that drugs accounted for the largest share of health expenditure in the national health accounts. Strategic purchasing in many situations such as in India would mean nothing more than reorienting and re-positioning health financing and service delivery systems for efficient and quality healthcare at lower costs. For example, a PBF component for operational costs along with a fixed budget for infrastructure, salary and other fixed costs and per-capita reimbursement for primary healthcare as envisaged by the new health policy, are just a few ways of ensuring maximum coverage and access to existing health services for people.

Finally, a personal opinion, on your proposed method of component based sequencing. Both strategic purchasing and the propaganda type roll-out of national health insurance may mean financial commitment by the governments. In certain situations, it may only mean better utilizing the existing budget by changing the way health providers get paid. Other situations such as referral of patients to private hospitals for specialized care may require additional budget and revenue raising. Therefore the components that need to be first in the sequence would entirely depend on the health needs of the population and the fiscal space for health within the government budget. I would conclude by saying that sequencing is a good idea to strategically approach the UHC goals, however, the sequencing has to be dynamic and based on the country-specific situation. Best.

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A. Munandar

5/4/2017 11:00:53 am

Thankyou

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Joe Kutzin link

5/4/2017 02:58:18 pm

Erik,

Want to add my congratulations on this post to those of the others who have replied, and of course add a few ideas. I am considering making it a required reading for our health financing course this year as background to our session on reaching people in the informal sector.

In my view, your post combines a functional approach to financing (and health systems more generally) with political insights into what seems to be working and not working. Implicit in your approach is a recognition that traditional approaches to health financing, often adopted from European experience with the development of social health insurance, has not had a lot of success. Indeed, in many cases, it has worsened existing inequalities in service use and financial protection.

Key to moving away from the traditional "UHC = UHInsurance = a specific arrangement involving contribution that begins with the formal sector" is to accept a move away from labels and towards functions (or components as you put it here). It also means recognizing that whether or not something bears the label "insurance", all arrangements other than OOP involve some degree of pooling and risk protection. So all countries – those on the African continent are no exception – provide this function of insurance for their population. The problem is that many do so very poorly. But starting from this mindset opens the opportunities to envisage different pathways to improving the use of prepaid funds to improve equity in service use and financial protection for the population; i.e. to move towards UHC. And consistent with your post, the idea has to be not only how to take immediate steps in that direction, but also how to strengthen the foundation for future progress as well.

Here at WHO we are sharing many of the concerns raised by you and the commenters - most particularly that there are too many strategies that don't get implemented, and that we have to put much more focus on implementation sequencing from both technical and political perspectives. While it is true that every country varies, I do see very strong reason to believe that in countries with large informal sectors and limited fiscal capacity, it makes both technical and political sense to start with purchasing. The key – and how we are trying to push the PBF movement a bit – is to not see this as an isolated reform to be celebrated but rather to design it explicitly as a step towards building a unified and universal health financing system.

Politics and health financing functions. Much of the inequalities and inefficiencies that we see in health systems today derive from fragmentation in pooling. But there is really no step-by-step approach to merging different funding pools (e.g. poor and formal sector, different insurance schemes, HIV vertical program funding and the general pool, etc.); you either do it or you don’t, and doing so often requires an act of Parliament. Purchasing of health services, on the other hand, can proceed more gradually. Build the information system, manage the data to use as a basis for paying providers, etc., and the rollout can move on a geographic or some other basis. It is also possible to run a “shadow” system for a while, managing the data and simulating what payments would be, but before putting money in. This can be used to develop capacity. This kind of thing really isn’t possible with pooling, though it should be possible to merge (or make inter-operable) the patient activity data across schemes even if the funds aren’t pool.

Anyway, given all of this, if merging of pools is the first “big bang” step of the reform process, you may never get to step 2. And if, by chance, there is political agreement and the big bang pooling happens, those managing the merged pool and responsible for paying providers may not yet have the experience and capacity. So there is a lot to be said – both politically and technically – for an approach that puts purchasing early in the sequence. I would argue that even before that (or simultaneously) is the information system that will be used. And if we are serious about thinking of the purchasing mechanism (e.g. as in PBF) as a step towards UHC, then another key early step is to universalize the information system. In other words, create a single, unified form to collect data on patient activity, with a clear vision that the country is creating a unified database. Again, that will allow for informed advance planning (simulations) about the inclusion of more services, more regions, or more populations within the payment mechanism.

Also strongly agree with your statements about where revenue raising fits within the sequence and priorities. This is another aspect of conventional wisdom that needs challenging. We should not see “health insurance” as some magic way to raise money. Instead, and on the logic that the country a

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Joseph Kutzin

5/4/2017 02:59:47 pm

[not the first time my comments exceeded the word limit!!]

Also strongly agree with your statements about where revenue raising fits within the sequence and priorities. This is another aspect of conventional wisdom that needs challenging. We should not see “health insurance” as some magic way to raise money. Instead, and on the logic that the country already has some type of “insurance”, even if that it just supply-side subsidies to public facilities, we need to see it as a way to re-organize the use of funds. One problem that often arises is that the very real concerns about levels of funding distract a new health insurance fund from its primary responsibility, which is to improve its provider payment mechanisms. Raising money and paying providers are two different functions. The health sector (and the health financing agency in particular) should focus on paying providers; leave the revenue raising to the MOF / national tax authorities. This might also be a way to avoid the entirely predictable but nevertheless unpleasant “surprise” that individual contributions from persons in the informal sector fall far short of what is planned. The context of LMICs is such that the great bulk of prepaid revenues need to come from the budget, not individual contributions. We should stop pretending that the health sector is going to do a better job of collecting prepayments than the tax authorities do at collecting income tax from people in the informal economy. A division of responsibility for implementing different functions is needed.

And of course, contributory-based entitlement tends to be associated with inequities, and where this is the foundation, those inequities become entrenched. The extension to the poor and/or informal sector either never happens, or happens with a much lower level of benefits. So moving away from this is generally a good idea. Here it is important to remember the underlying philosophy of UHC – we are talking about health coverage as a right, not an employee benefit. For any country (of any income) that is serious about UHC, someone’s employment status should be irrelevant.

My only quibble is technical/definitional, perhaps. My understanding of PBF is that it is comprised of a payment mechanism linked to a defined benefit. That benefit may be free MCH, or free health center visits, or hospital delivery with a limited fixed copay, or free TB treatment, or whatever. So if PBF is to be starting point of financing reforms for UHC, then we should recognize it as a funding pool (from whatever source) from which providers are paid for a benefit that is defined on a non-contributory basis, and over which providers have some degree of autonomy in terms of management. From here, the “path towards UHC” involves gradual extension of service coverage or cost-sharing coverage as the pool grows (or more population coverage if the extension is geographic). And fundamentally, which is what I think your message is, though in my very long-winded way, this is probably a better bet for coverage expansion than is trying to do so through efforts focused revenue raising and pool defragmentation. I would never take pool defragmentation off the table, of course, but my latest slogan is to “pool the data before you pool the money”, which can be a step towards that eventual “slow bang”…

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Sachin Bhokare

5/5/2017 04:23:37 am

Dear Erik

Thank you very much for writing on this very important topic. I am completely an agreement with you on component based sequencing approach for successful implementation of National health insurance program.

Experience of health insurance program at National and state level in India is not very different as you have pointed out in Africa. These programs are facing multiple challenges in terms of governance, benefit package, service delivery, empanelment of providers, enrollment, utilization of services, and misuse of program by service providers. In recent past many programs were came into existence by various state governments with classical approach that you have mentioned, some of them are very successful because of appropriate use of resources and technology, while others are still struggling with multiple implementation issues.

The formation of these programs are explicit to the political benefit, hence the initial design related to coverage of population, services, and financial protection are based on the political will and future benefits. Once these program take off and political situation is stable, one can work on series of reform or improvement which can be similar to component based sequencing. I am fully agree with you on strategic purchasing is the starting point as it would lead to all other aspects of programs.

This can be achieved through frequent knowledge transfer events. Owners of program, policy makers, and experts can come together and discuss particular topic (Enrollment, Utilization, Benefit Package, Fraud, Technology, etc.) in detail. It was evident in India that many programs adopted the good practices of others and improved the overall functioning.

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Dr. A. Munandar

5/5/2017 04:45:15 am

Thankyou, Sir. Please sent by me

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

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