Challenges in Health Sector Reform for Low-Income Countries

1. Issues in Health Sector Reform in low income countries/aid dependant countries

2. Broad Overview • Lack of evidence base • Systems historically based • Influence of Development agencies -huge • Language –acronyms • Frequent change in international policies • Politicians timeframe dictates pace of new initiatives

3. Key Tools • Understanding health seeking behaviour • Health Accounts • Household Surveys DHS –Demographic and Household survey • Rapid Participatory assessments • Anthropological surveys

7. National Health Accounts • Key questions: • what is the total spending on health? • who is spending it (poor, rich, rural, urban) • what is it being spent on (primary health care, hospitals, MoH headquarters etc.) • what are the sources of this expenditure (Government, donors, NGOs, private)

8. National Health Accounts • Key questions: • how does expenditure compare to others • are funds efficiently allocated and spent • what can be done to improve the financing of health services • increasing the level of resources available • using and allocating resources more effectively

9. Level of public expenditure (at purchasing power parity) $10 or less per head: Cambodia, Nigeria $10 - $30 per head: China, Ghana, India, Pakistan, Uganda, Tanzania $30 - $100 per head: Egypt, Kazakhstan $100 - $300 per head: Brazil, Colombia, South Africa Source: WHO World Health Report 2000 (1997 figures)

10. Wealth Inequalities inUnder-5 Mortality: Select Countries

11. Health financing mixes 11 Sources: Wagstaff, van Doorslaer, et al. (1998), Parker and Pier (1999), Lasprilla et al. (1999), Theodore et al. (1999), Wagstaff, van Doorslaer, Watanabe and Xu (1999)

13. Health Expenditure Per capita Public Private Bangladesh $16 34% 66% Bolivia $53 20% 80% Cameroon $ 26 20% 80%

14. Health expenditure in low and middle income countries • Most expenditure is private • Most private expenditure is out of pocket • Most goes on pharmaceuticals • Poor may spend greater % of household income than the rich • They fund it by borrowing at high interest rates

15. Broad overview • Increasing role of the private sector • Failure of the public sector • Plurality of providers • Out of pocket expenditure dominates • OECD health economic models don’t apply

16. Category 1991/92 1993/94 1995/96 1996/97 1997/98 Primary Care: -Service Delivery 34.8 34.0 34.0 26.6 24.9 -Support Services 6.3 6.1 7.7 7.9 7.6 -National Health Programmes. 35.7 32.7 21.7 29.4 24.7 Sub Total 76.8 72.8 63.4 63.9 57.2 Health Policy and Management 5.7 4.4 3.2 2.5 2.5 Hospitals[1] 14.6 20.0 30.0 30.6 37.5 Traditional Medicine 2.9 2.8 3.4 3.0 2.8 TOTAL 100.0 100.0 100. 100. 100. Trends in Budget Allocation Shares by Major Components-Nepal

17. Orissa India: who benefits from publicly funded hospitals

18. Public Health Sector Particular problems include: • A shift of resources from the primary care sector to the hospital sector • A shift in resources from rural areas to urban ones • Limited geographical coverage especially in remote areas where trained personnel are unwilling to work • Reluctance of consumers to use public facilities because they cannot provide much-there are frequent or permanent drug shortages and staff capacities and attitudes leave much to be desired

19. Public Health Sector Causes: • Staff often earn very low wages • Lack of management authority at provider level because of employment legislation • Lack of staff incentives • Limited prospects for earning a living in a poor rural area and the limited living conditions • The political influence of the middle classes

22. Quote from one sub-Saharan country ‘ The hospital is my farm, the patients are my sheep, how else would my family eat’

23. Proportion of service users by provider-Bdesh • 2000 2003 • Unqualified 52% 60% • Private qualified 31% 27% • Govt 17% 13%

24. Exercise • In Nigeria what proportion of drugs sold in rural pharmacies are useless?

25. Do they get good value for money? • They buy fake or dangerous drugs • They buy the wrong dosage • They buy from unskilled health workers But…. Doctors not necessarily any better

26. Proportion of users with full explanation -Bdesh 2000 2003 • Govt 50% 44% • Private qualified 71% 80% • Unqualified 68% 73%

27. Cost ratio-Bdesh • Unqualified 1 • Govt 2 • Private qualified 4

28. Biggest issue-Capacity • Most Health ministries in low income countries have less capacity than a primary health care trust • Dhaka (population 15million) has a public health dept of six doctors plus EHOs and admin staff

29. Exercise • You are the World Bank task manager for the health sector in a low income Asian country. What do you see as the five most important issues that need to ( and can ) be addressed in the next five year health strategy?

30. Aid Instruments: Doing Good???? • G8 governments have a major commitment to improve health in poor and middle income countries: • emerging/growing diseases (TB, SARS, HIV/AIDS) • reducing poverty • 5 of the 8 MDGs are health related • world security • Goal: 0.7% of GNI of OECD countries on aid (now average of 0.4%)

31. Aid • Aid transfers for health growing at 3% pa,now at over US$5 billion pa • Of this, US$1 billion is technical assistance OECD, five year moving averages 1978-98

32. International Development Targets/Millennium Development Goals By 2015: •  by 2/3 rate of inflation & child mortality •  by ¾ the rate of maternal mortality • attain universal access to reproductive health services •  by 25% in HIV infection in 15-24 yr olds

34. Role of EDPs • Focus on Poverty Reduction • Focus on MDGs • Sector Wide Approaches –SWAPs • New Initiatives

35. Current focus of DPs • Focus on poverty reduction through Poverty Reduction Strategies-PRSPs • Move to Debt Relief • Move to budget support monitored through PRSPs –moving upstream • Harmonisation ?????? Aid lite

36. Sector Wide Approaches - SWAPs EDPs shift from donors to investors Elements include: • an agreed health strategy • a medium term expenditure framework for the health sector which can deliver the strategy • a sector investment plan which will deliver the strategy • a financing mechanism which clearly shows government and EDP inputs

37. SWAp - definition • All significant public funding for the sector supports a single sector policy and expenditure programme • Under Government leadership • Common approaches adopted across the sector by all funding parties • Progression towards relying on Government procedures to disburse and account for all public expenditure, however funded

38. Criteria for a SWAP (1) All of the following: • Comprehensive sector policy and strategy • Annual sector expenditure programme and Medium Term Sectoral Expenditure Framework • Donor coordination is government-led • Major donors provide support within the agreed framework

39. Criteria for a SWAP (2) At least one of the following: • Significant number of donors committed to moving towards greater reliance on government financial and accountability systems • Common approach by donors to implementation and management

40. How wide is sector wide? Ideally includes • All activity, financing and participation in the sector • Civil society actions, e.g. in health • insurance schemes • employee health services • cooperatives • expenditures by private individuals In reality • Most concerned primarily with the public sector

41. A new way of doing business • Partnership between government and donors in all stages of strategic development, management and assessment • Donor-led to country-led development • Donors and government accept joint accountability and relinquish attribution • Bilateral arrangements managed collectively according to an agreed programme • Environment of increasing mutual trust leading to higher levels of financial and institutional risk

42. Threats / challenges to the process (1) • Vision may rest with only few individuals • Stakeholders in existing system v reformers • Institutional set up at sector level not conducive to new ways of working • Productive sectors very complex • Meaningful participation of the poor

43. Threats / challenges to the process (2) • Multiple stakeholders; ministries; sections of ministries • Donor competitiveness/need for attribution • Pressures of donors “spending horizons” • Dependency of sector reforms on wider public sector reforms overall • Complexity of decentralisation process

44. Problems of drawing in NGOs and Private Sector • No single voice • Inadequate information access • Not influential at policy level • Governments unreceptive • SWAP as threat • Views on modalities mixed • Not all CSOs are interested • Independent players • Private sector seen as body to be regulated

45. SWAps, PRSs, and Direct Budget Support • SWAp as a process in which…. • Gradual increase in the share of funds transferred to government management • Moving toward sector budget support • In the context of national poverty reduction programmes: • move towards general budget support • with or without notional earmarking to sectors

46. Focus on DPs • On public sector • However key issue is how to get better value for the out of pocket expenditure by the poor

47. Global Initiatives for health • Fashion- centre need to come up with new initiatives • Failure of health systems to deliver • Small pox programme success • EPI people came out of the cupboard • Very attractive to politicians • Very attractive to other funders

48. Global Health Partnerships • GFATM • GAVI • RBM • GPEP • Stop TB partnership • MCT plus • Healthy newborn partnership

49. Global Initiatives for health • GAIN • Access to medicines • Grand challenges in global health programme • DNDi • MVI • MMV

50. Global Initiatives for health • TB alliance • IAVI