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Pathways to universal health coverage in fragile and transition states

CSO FORUM, Washington DC, October 12, 2013. Pathways to universal health coverage in fragile and transition states. CORDAID: SOME Facts & figures. 540. 38. staff. 2,000. projects. countries. 129 million. 316,000. euros of disposable funds. 459. Private donors. 92. 99.

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Pathways to universal health coverage in fragile and transition states

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  1. CSO FORUM, Washington DC, October 12, 2013 Pathways touniversal health coverage in fragile and transitionstates

  2. CORDAID: SOME Facts & figures 540 38 staff 2,000 projects countries 129 million 316,000 euros of disposable funds 459 Private donors 92 99 FIELDPARTNERS funding partners years experience

  3. Cordaidhealthcare Cordaid Healthcare: Improving access and quality healthcare • Cordaid Healthcare is based on three pillars: • Health System Strengthening (including RBF/PBF strategies) • Women’s health (and SRHR) • Health Investment Fund Slide 3 The Hague 1 October 2013

  4. Cordaidhealthcare Key Facts Total working budget Cordaid HealthCare 2013: 70 million euros • Healthcare focus countries: • Afghanistan, Bangladesh, Burundi, Cameroon, • Central African Republic, Congo Brazzaville, • Congo DR, Ethiopia, Ghana, Haiti, Malawi, Rwanda • Sierra Leone, South Sudan, Uganda and Zimbabwe Slide 3 The Hague 1 October 2013

  5. outline panel

  6. UHC in FRAGILE AND TRANSITION STATES: a conversationbeyond the comfort zone Universal Health Coverage in fragile & transition states • Kick-off presentation by dr. Godelieve van Heteren (15 minutes) • The Universal Health Coverage (UHC) Crescendo: Rebranding or Radical rethink • Cordaid study “UHC in fragile and transition states”: scope, methodology & core set of questions • First observations: from literature survey and interviews • Three key issues for panel • Panel discussion on the three selected key issues (1hour) with • dr. DionisNizigiyimana (PS MSPLS, Burundi) • dr. NyashaMasuka (PMD MoHCW, Zimbabwe) • dr.AkikoMaeda (HNPHDN, World Bank) • mr. Christian Habineza (HDP, Rwanda) • mrs.ArjanneRietsema (Cordaid) • 3. Conclusions and follow-up by mrs.ArjanneRietsema (Cordaid) (10 minutes) Slide 4 The Hague 1 October 2013

  7. 1. The uhc CRESCENDO: REBRANDING OR RADICAL RETHINK’

  8. 1. UNIVERSAL HEALTH COVERAGEthe making of an agenda UHC in fragile and transition states UHC Crescendo: The Making Of an Agenda • 2005: World Health Assemblycalledongovernments to “developtheirhealthsystems, sothat all people have access to services and do notsufferfinancialhardshippayingforthem.” • 2010: WHO devoteditsannual World Health Report to a discussion of health care financingalternativesforachievinguniversalcoverage. • 2012: United Nations General Assemblycalledongovernments to accelerate the transitiontowardsuniversalaccess to affordable and qualityhealthcare services • 2013: Processtowards post-2015 agenda: UHC to succeedhealthMDGs as solehealthrelatedsustainabledevelopment goal • >> 2012: rapidlygrowingnumber of position statements by international agencies and NGOs (from to Oxfam), framing the debate SLIDE 5 The Hague 1 October 2013

  9. 1b. UNIVERSAL HEALTH COVERAGE‘new’ sustainable development goal UHC in fragile and transition states • Increasingnumber of global promotors of UHC agenda: WHO, the World Bank, UNICEF, USAID, the Inter-AmericanDevelopment Bank, the Rockefeller Foundation, B&M Gates Foundation and others • Programs in manymiddle-incomecountries, low-incomecountries are alsoconsideringlaunchingsimilar programs. • See: • Universal Health Coverage Forward Initiative (http://uhcforward.org) • Joint Learning Network for UHC (http://jointlearningnetwork.org) • WHO country pages (http://www.who.int/countries/en/). SLIDE 5 The Hague 1 October 2013

  10. 1c. UNIVERSAL HEALTH COVERAGEdefinitions and interpretations UHC in fragile and transition states • The WHO defines the goals of UHC as: • Attempts to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. • Both demand and supply side issues: • Protection against financial risks • Availability of quality health care for the entire population / quality health services • In practice, multiple interpretations of the concept>> multiple foci SLIDE 5 The Hague 1 October 2013

  11. 1d. UNIVERSAL HEALTH COVERAGEdimensions of coverage UHC in fragile and transition states SLIDE 5 The Hague 1 October 2013

  12. 1e. Critical contributors UHC in fragile and transition states • The World Bank: e.g. with Universal Health Coverage Studies Series (UNICO Series) and Universal CoverageAssessment Tool (UNICAT) To developknowledge and operational tools designed to help countries tackle the implementationchallenges in waysthat are fiscallysustainable and thatenhanceequity and efficiency. Technical papers & country case studies (22 countriescompared to Massachusetts) that analyse different issues and dimensions of UHC. SLIDE 5 The Hague 1 October 2013

  13. 1F. Lessons learned From studies so far UHC in fragile and transition states Multiple pathwayspossible, noonesize fits all. Manyinstruments & institutionsneed to bedeveloped. Affordability is important foraccessbutnotenough: more holisticapproach to otherdimensions of accessneeded Target the poorbut keep aneyeon the non-poor: in extendingschemes to the poorotherdimensions of accessmaygainimportance and require different strategies Benefitsshouldbecloselylinked to target population’sneeds: look into indicators of populationneeds, of barriers to access, unsatisfieddemands, sources of financialhardship Highlyfocusedinterventionscanbe a usefulinitial step but beware of simplisticintroductions of schemes SLIDE 5 The Hague 1 October 2013

  14. 2. CORDAID qualitative study ‘uhc in fragile and transition states: scope methodlogy and timeline’

  15. 2. Cordaid: what about UHC in fragile and transition states UHC in fragile and transition states Wishes to relate the subject of UHC to developments in fragile and transition states with special attention to potential state- and peacebuilding impact. UHC appropriate? Feasible? With what prerequisites and emphases?’( the paradox of talking about ‘universal coverage’ without being ‘universal’ in application) Wishes to engage with the UHC agenda by critically revisiting the roles of CSOs in fragile and transition states. Specific (new?) roles for CSOs with regard to the UHC agendas? SLIDE 5 The Hague 1 October 2013

  16. 2B. Cordaid UHC study:SCOPE UHC in fragile and transition states • Aims • To assess the perceived value and feasibility of UHC in fragile and transition states, with special attention paid to state- and peacebuilding effects. • Scope • Predominantly qualitative study among local stakeholders in four countries, as input for Cordaid position paper on UHC to be issued in December 2013, directing future efforts. Basis: literature survey, decision-maker perception study, expert panels. • Focus • Four countries in which Cordaid has been engaged in health systems development and RBF, of which 2 post-conflict and 2 transition SLIDE 5 The Hague 1 October 2013

  17. 2C. Cordaid UHC study:methodology UHC in fragile and transition states • May-June 2013: Literature review • By dr. Sven Neelsen (Institute Health Policy and Management, Erasmus University Rotterdam) and dr. G. van Heteren (Rotterdam Global Health Initiative, Erasmus University Rotterdam) • July-September 2013: Semi-structured interviews with 78 decision-makers in Afghanistan, Burundi, Rwanda and Zimbabwe • By dr. Said Shamsul Islam (Afghanistan), dr. LonginGashubije (Burundi), dr. LaetitiaNyirazinyoye (Rwanda) and dr. Sue Laver (Zimbabwe) • October-November 2013: Feedback sessions and review panels • CSO session World Bank, Washington DC and Cordaid Review Panel • December 2013: Final drafting position • By Cordaid SLIDE 5 The Hague 1 October 2013

  18. 2c. Cordaid uhc study:methodology (2) UHC in fragile and transition states Questionnaire: mainsections of investigation • General conceptualunderstandingby important stakeholders • Existingordeveloping UHC policies in more detail • UHC implementationpractice: practical programs & UHC dimensions (financialcoverage, service deliveryetc) • UHC making a difference and roleCSOs: newstakeholders, alliances, roles, effects, impacts? SLIDE 5 The Hague 1 October 2013

  19. 2c. Cordaid uhc study: methodology (3) UHC in fragile and transition states Awareness: Who is aware of UHC as a policy goal: to what extent does the subject live beyond policy-circles, and how is it perceived? UHC old or new: How innovative is the agenda, does it open up new avenues or merely ring ' same old stories'? Are there any new stakeholders involved? Drivers of UHC: Who are the perceived drivers of the UHC agenda so far and by whom is this agenda 'owned'? Main emphases: How is UHC chiefly configured in the various countries participating in the study: is the focus primarily on financial access, on extending services, on improving quality or a mixture of all these dimensions? Pro-poor: Is the current international UHC agenda perceived as pro-poor or as mainly developed for better off in middle and high income countries? What are the perceived mechanisms to make it an inclusive agenda, how feasible are they perceived to be? • Interview key question areas SLIDE 5 The Hague 1 October 2013

  20. 2c. Cordaid uhc study: methodolgy (4) UHC in fragile and transition states Interview key question areas 6. Practical Strategies: Which ideas exist on how to advance the UHC agenda and how to proceed? Are there things to be learned from others? 7. Do RBF/PBF approaches matter: Results- and performance based approaches to health financing and management are promoted everywhere, how do they impact on UHC according to interviewees? 8. Specific Pathways: Do fragile or transition states require specific pathways or rather not? 9. Any visible difference in practice: Does the UHC agenda make any perceivable difference as yet in the four countries? 10. Prerequisites: What are prerequisites, what preconditions should be fulfilled? SLIDE 5 The Hague 1 October 2013

  21. 3. first observations

  22. 3. Cordaid uhc study: first observations from literature review UHC in fragile and transition states Heterogeneity of schemes abound Limited transferability of successful models to fragile states Robust evidence on impact of health reforms in fragile states is sparse but some indications are emerging of requirements and caveats regarding various financing strategies. Much concerted effort needed to produce further evidence on particular interventions in fragile state contexts. (little encouraging evidence on voluntary insurance schemes; emerging positive evidence on RBF but for all: further attention to equity and sustainability necessary) SLIDE 5 The Hague 1 October 2013

  23. 3b. Cordaid uhc studyfirst observations from literature survey UHC in fragile and transition states Causal evidence for role of health system renovation efforts in state-building need to be further developed. While many transmission channels are thinkable and discussed in theory, causal evidence on the link between UHC efforts and state-building has yet to emerge. Importantly, scholars underline that quick fixes to defunct fragile state healthcare systems – like contracting out to international NGOs may be successful in improving health outcomes in the short run, but bear the danger of further delegitimizing national governments if their own ability to provide policies, financing and services is not concurrently developed. SLIDE 5 The Hague 1 October 2013

  24. 3c. Cordaid uhc studyFIRST OBSERVATIONS FROM the INTERVIEWS UHC in fragile and transition states • AWARENESS/ OLD-NEW? • Awareness mainly among policy-makers. • From Afghanistan> Burundi> Rwanda> Zimbabwe increasing degree of organized attention at policy level. • Trickle down effect limited. Field parties unless invited to government workshops have little idea. Perceived as top-down strategy • Frequently associated with existing policy strategies (e.g. NHS Zim, NHSP or PRS in Burundi etc.) • Associated with Health for All: stirring both positive and negative sentiments: ‘Same old thing with new words’ versus ‘new avenues’ • In core of ministries of health: especially associated with attempts to find new strategies for integrated health financing and decreasing donor dependency SLIDE 5 The Hague 1 October 2013

  25. 3C. Cordaid uhc studyFIRST OBSERVATIONS FROM the INTERVIEWS (2) UHC in fragile and transition states • DRIVERS AND EMPHASES/ PRO-POOR? • Complex set of answers on who should be driving the process and division of labor • Perceived as largely driven by big donors and international agencies and hence taken up by governments (UH just more of the same, another global cliché, ‘invented by people in well furnished rooms with comfortable salaries’). • But may offer an opportunity to deliver services through locally driven and locally funded interventions, and ongoing efforts to reach the poor/targeted at marginalized. • UHC is perceived by some to hold a promise for a more tangible intervention mix with better defined concrete objectives around access, financing and quality and more so in countries in which domestic health financing is already growing as a policy theme • Some confidence that UHC will also stimulate better pro-poor strategies SLIDE 5 The Hague 1 October 2013

  26. 3C. Cordaid uhc study: FIRST OBSERVATIONS FROM the INTERVIEWS (3) UHC in fragile and transition states PRACTICAL STRATEGIES/ ANY VISIBLE DIFFERENCES Key perceived difference is a renewed emphasis on alignment of policies, decreasing donor dependencies, increasing domestic health financing/policy possibilities (taking the drivers seat domestically) and demand for more equitable health financing strategies. As a consequence more mechanisms re these subjects are explored and the spotlights become even more firm on existing barriers in fragile and transition states: burgeoning informal sector, tax exemptions for some high value sectors as negatively impacting on ability to finance health care domestically SLIDE 5 The Hague 1 October 2013

  27. 3c. Cordaid uhc study: FIRST OBSERVATIONS FROM the INTERVIEWS (4) UHC in fragile and transition states Resetting of priorities towards informed decision-making: strong data needed. RBF/ PBF seen as beneficial to this agenda Capacity for accountability should be increased, growing demand PBF/RBF strategies fit these agendas SLIDE 5 The Hague 1 October 2013

  28. 3c. Cordaid uhc study:First observations from the interviews (5) UHC in fragile and transition states SPECIFIC PATHWAYS TO UHC IN FRAGILE STATES OR SPECIFIC PREREQUISITES? • Interviewees indicate their country’s situation is ‘unique’ but the financial strategies subsequently mentioned are not specific. They cover the whole range of financial strategies for domestic health finances (taxes etc)>> the ‘other dimensions’ need to be deeper researched • Shared growing interest in the search for specific domestic health financing mix • Shared interest in the extra supply side attention which is needed needed • Shared interest in how better analyses are needed on how to reach the population • New mapping and exploration of private sector involvement deemed necessary • More emphasis on political will, accountability and ownership: the wrestling with donor dependency and external agencies SLIDE 5 The Hague 1 October 2013

  29. 6. three key issues for paneldiscussion

  30. 6. Three SETS OF questions for panel UHC in fragile and transition states • How do you perceive the development of a UHC agenda in your country and do its current frames stimulate any new approaches to improving health coverage? If not, what should be done instead? • Does the UHC agenda contribute to health systems strengthening, stabilization, and state building in your country and if so, how? • 3. Are there any new players in this field who have gained importance or who should be involved ? What should be the role of CSOs in advancing UHC? How radical are the stakeholders willing to rethink their own positions? SLIDE 5 The Hague 1 October 2013

  31. For more information please contact:Remco Van der VeenDirector HealthcareE: remco.van.der.veen@cordaid.nl

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