Universal Health Coverage : How does your ( RBF or not RBF) solution fare ?

1. Universal Health Coverage: How does your(RBF or not RBF) solution fare? Bruno Meessen, ITM & PBF CoP Expert Talk, Eschborn, December 12th 2012

2. An assessment of the problem • Health situation in LICs is unacceptable: • Overall status (health / socialprotection); • Inequity, esp. the poorest. • Yet, we knowpretty well the interventionswhich are needed. • Health system delivery is part of the problem.

3. USE OF BASIC MATERNAL AND HEALTH SERVICESCoverage Rates among Lowest and Highest 20% of the Population in 56 Developing and Transitional Countries (David Gwatkin, 2007)

4. Contributionto UHC as the bottom line “Everyoneshouldbeableto access health services and notbe subject to financial hardship in doingso”. (WHA resolution 58.33 2005). Couldonestructure a bit the contribution of a scheme / initiative / solution to UHC?

5. The 12 desirabletraits of anypotential solution • Such a solution builds the pathtouniversalcoverage, by: Increasing direct benefits to the priority groups. • (1) Increasing resources to health. • (2) Reducingbarriers, especiallyfor the most vulnerablegroups. • (3) Paying attention toquality of service in public facilities. • (4) Enhancinganefficientuse of resources. • (5) Payingattention toquality of care, across the board. • (6) Protectingagainstimpoverishment. Consolidating the system. • (7) Fixing ‘health system problems’. • (8) Beingharmoniouswithother health strategy. • (9) Notundermining control bynational health authorities… • (10) But improvingtheir accountability and contributeto overall bettergovernance. • (11) Beingscalable, sustainable and appropriate as a stage in a long-term process. • (12) Consolidating the political momentum for UHC and rightsto health.

6. (1) Contributeto resource mobilisation • Does the solution increasealtruism/solidarity, trust and financial commitmentby tax payers, Ministry of Finance, donors and tax payersfrom the North? • Does itenhancedisbursmentof the allocated budget? • Ideal features: • Predictibility. • Deliver benefits (in kind or cash) directlyto target groups. • Traceability. • Complete contract. • Mismanagement-proofed. • NB: (1) the environment has changed; (2) the future of health care financing in most LICs is national resources (domesticrevenue).

7. (2) Removebarriersfacedby the users, and the most vulnerable in particular • Quitepoor performance of the dominant model (NHS with free preventive services and user feesforcurative services). Cf. David Gwatkin analyses. • Can the solution target resources (ifneeded)? • What is itsscale? • Does the solution addressremainingbarriers on the demand side, at leastfor the most vulnerable? • Out-of-pocket paymentforcurative services. • Distance. • Transport. • Knowledge.

8. (3) Improvequality of services • The role of barriers on the supply side isunderestimated. Theirvulnerabilityto health facility managers as well. • Will the solution bringaboutimprovements in terms of: • Availability of qualifiedstaff. • Availability of drugs. • Cleanliness. • Opening hours. • Friendliness. • Queues. • Respect of dignity. • …

9. (4) Improve efficiency • Value for Money is notan agenda of donors only. Cf. Kaberuka 2011. • This is a requirementforall resources – includingprivate and public resources. • Does the solution contributetogreater : • Allocative efficiency (promote high impact interventions). • Technical efficiency (get the maximum from the staff, equipment and infrastructure). • ‘Transactional’ efficiency (limited transaction costs)

10. (5) Improvequality of care • Efficiency requireseffectiveness of treatment. Quality of care is a hugeproblem in manyLICs, across the board. • How does the solution addressquality of care? • Keep in mind thatquality of care has manydeterminants, somecanbeinfluencedby health facility managers. Some components are verifiable ex ante, some ex post, some are not. • Whatabout the Private for Profit providers?

11. (6) Reduce risk of impoverishment • How does the solution protectagainstcatastrophic health care expenditure and incomeloss / iatrogenicpoverty? • In the public sector, but also in the private sector. => It is aboutinsurance, but alsoregulation of providers and shaping health seekingbehaviours.

12. Manyinterventions show some of these 6 traits. But a UHC friendly solution shouldalsofulfill 6 other ‘systemic’ requirements.

13. (7) Addressstructural health system problems • Does the solution contributeto • Better performance by the public facilities, support services (e.g. drug supply) and administration (e.g. SIS); • Fair treatment of the private notforprofit; • Harnessingthe private forprofitproviders? • Some interesting tracks: • Voice and exit mechanisms, separation of functions, clarification of missions, contract, purchaser-provider split, autonomy, neutralitytoownership of the providers, independent verification, measurement, sanction.

14. (8) Harmonizationwithotherinterventions • Manywaysto respect the first 6 components. • Is your solution in line withotherinterventionsrespecting the 6 traits? Does it help to counter / correct solutionswhich do not respect the 6 first traits? • A particular risk for UHC: multiplication of schemes; vertical approaches; loss of the mainobjective.

15. (9) Consolidateleadershipby the Ministry of Health • The solution shouldnotbeforcedfromoutside. Political and technicalleadershipbynationalauthorities is neededforsustainability, but also as a mechanismtoensure (8). • Is the solution implemented in such a way thatitempowers the MoH (esp. in donor dependent countries)?

16. (10) Contributeto overall bettergovernance • Trait 9 shouldnot conflict withaccountability tocitizens. • Poor performance of the health sector is indeed also the outcome of constraintsoutside the sector, includinglack of accountability. • The solution shouldcombat/shortcutembezzlementand fraud; care fortransparency; resistpressurefromvestedinterestsbyestablishing a culture of policy experimentation, monitoring and evaluation.

17. (11) Scalability, sustainability and pathdependency • Is the solution scalable, sustainable and putting the health system on a goodpath? • Scale: canyouensurethatallindividualsbelongingto the target group are covered? • Ifsustainabilityis required, can the solution beintegrated in public fundingand operatedbynational actors? • Pathdependency: how does the solution affect the balance of power for stakeholders such as insurees, providers, private insurance funds, pharmaceutical sector…?

18. (12) Consolidating the UHC momentum • We are technicians, but UHC is aboutpolitics. Cf. Thailand, Rwanda, Venezuela! • Does the solution get visibility at voter level? Politicalpay-off? • Does itconsolidaterightsto health?

19. Ourrough assessment • Many RBF solutions score pretty well on these 12 traits. • Some RBF approaches score betterthansomeothers on sometraits. => How do othersthinkaboutthis?

20. RBF, strategic purchasing and the agenda of health financing for universal coverage • Efficiency (more health for the money) as one of the key pathways to Universal Coverage identified in WHR2010 • Strengthening purchasing is a key to building domestic health financing systems • It means using information on provider performance or population health needs to drive resource allocation • Builds capacity; people have to analyze and use this information for decision-making • Changes system culture, shakes up bureaucratic inertia • RBF – PBF – P4P etc. are all examples of strategic purchasing Joe Kutzin

21. As with health insurance schemes, think from scheme to system with PBF • PBF/RBF should not be run like a "scheme" or "project", but as a step in the process of moving systems towards more strategic purchasing • Long-term capacity building for the purchaser (and investing in understanding by the providers) is much more important than trying to "prove" whether it works or not (because we know that passive budgeting or unmonitored fee-for-service does not work) Joe Kutzin

22. A bad RBF project… • …is run by donors (or institutionalizes the idea that the money for these incentives will be managed separately) • …overdoes the financial incentives in a way that can't be sustained by the government • …is only interested in "proving that it works" in the short run, rather than always acting with the intent to move from scheme to system • …overwhelms domestic capacity with too many new things to monitor • …does not address the institutional platform that will, in the future, be required to attract and retain the people with the necessary skills to be good purchasers Joe Kutzin

23. Operation: our assessment • RBF canbe a tool forbilateralaidtocontributeto UHC. • Bilateralaidcan help in trying out new strategies. • Coordinationwillbekey.

24. Thankyou.