pathways to universal health coverage in fragile and transition states

CARE. ACT. SHARE. LIKE CORDAID

PATHWAYS TO UNIVERSAL HEALTH COVERAGE IN FRAGILE AND TRANSITION STATES

CSO FORUM, Washington DC, October 12, 2013

CORDAID: SOME FACTS & FIGURES

540

129 million38

316,0002,000

99

staff

euros of disposable funds

countries

Private donors

years experience

projects

92 funding partners

459FIELDPARTNERS

CORDAID HEALTHCARE

Cordaid Healthcare: Improving access and quality healthcare

Cordaid Healthcare is based on three pillars:

1. Health System Strengthening (including RBF/PBF strategies)

2. Women’s health (and SRHR)

3. Health Investment Fund

SLIDE 3 THE HAGUE 1 OCTOBER 2013

CORDAID HEALTHCARE

Key Facts

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


Total working budget Cordaid HealthCare 2013: 70 million euros

SHARE. ACT. CARE. LIKE CORDAID

OUTLINE PANEL

UHC IN FRAGILE AND TRANSITION STATES: A CONVERSATION BEYOND THE COMFORT ZONE

Universal Health Coverage in fragile & transition states

1. 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

2. Panel discussion on the three selected key issues (1hour) with• dr. Dionis Nizigiyimana (PS MSPLS, Burundi)• dr. Nyasha Masuka (PMD MoHCW, Zimbabwe)• dr. Akiko Maeda (HNPHDN, World Bank)• mr. Christian Habineza (HDP, Rwanda)• mrs. Arjanne Rietsema (Cordaid)

3. Conclusions and follow-up by mrs. Arjanne Rietsema (Cordaid) (10 minutes)



1. THE UHC CRESCENDO:

REBRANDING OR RADICAL

RETHINK’

THE HAGUE 1 OCTOBER 2013

1. UNIVERSAL HEALTH COVERAGETHE MAKING OF AN AGENDA

UHC in fragile and transition states

UHC Crescendo: The Making Of an Agenda

• 2005: World Health Assembly called on governments to “develop their health systems, so that all people have access to services and do not suffer financial hardship paying for them.”

• 2010: WHO devoted its annual World Health Report to a discussion of health care financing alternatives for achieving universal coverage.

• 2012: United Nations General Assembly called on governments to accelerate the transition towards universal access to affordable and quality healthcare services

• 2013: Process towards post-2015 agenda: UHC to succeed health MDGs as sole health related sustainable development goal

• >> 2012: rapidly growing number of position statements by international agencies and NGOs (from to Oxfam), framing the debate


1B. UNIVERSAL HEALTH COVERAGE‘NEW’ SUSTAINABLE DEVELOPMENT GOAL


• Increasing number of global promotors of UHC agenda: WHO, the World Bank, UNICEF, USAID, the Inter-American Development Bank, the Rockefeller Foundation, B&M Gates Foundation and others

• Programs in many middle-income countries, low-income countries are also considering launching similar 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/).

http://uhcforward.org/

http://www.who.int/countries/en/


1C. UNIVERSAL HEALTH COVERAGEDEFINITIONS AND INTERPRETATIONSUHC 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


1D. UNIVERSAL HEALTH COVERAGEDIMENSIONS OF COVERAGEUHC in fragile and transition states


1E. CRITICAL CONTRIBUTORS


The World Bank: e.g. with Universal Health Coverage Studies Series (UNICO Series) and Universal Coverage Assessment Tool (UNICAT) To develop knowledge and operational tools designed to help

countries tackle the implementation challenges in ways that are fiscally sustainable and that enhance equity and efficiency. Technical papers & country case studies (22 countries compared to Massachusetts) that analyse different issues and dimensions of UHC.


1F. LESSONS LEARNED FROM STUDIES SO FAR


1. Multiple pathways possible, no one size fits all.2. Many instruments & institutions need to be developed. 3. Affordability is important for access but not enough:

more holistic approach to other dimensions of access needed

4. Target the poor but keep an eye on the non-poor: in extending schemes to the poor other dimensions of access may gain importance and require different strategies

5. Benefits should be closely linked to target population’s needs: look into indicators of population needs, of barriers to access, unsatisfied demands, sources of financial hardship

6. Highly focused interventions can be a useful initial step but beware of simplistic introductions of schemes


2. CORDAID QUALITATIVE

STUDY ‘UHC IN FRAGILE

AND TRANSITION STATES:

SCOPE METHODLOGY

AND TIMELINE’


2. CORDAID: WHAT ABOUT UHC IN FRAGILE AND TRANSITION STATESUHC 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?


2B. CORDAID UHC STUDY:SCOPEUHC in fragile and transition states

AimsTo 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.

FocusFour countries in which Cordaid has been engaged in health systems

development and RBF, of which 2 post-conflict and 2 transition


2C. CORDAID UHC STUDY:METHODOLOGYUHC in fragile and transition states

May-June 2013: Literature reviewBy 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. Longin Gashubije (Burundi), dr. Laetitia Nyirazinyoye (Rwanda) and dr. Sue Laver (Zimbabwe)

October-November 2013: Feedback sessions and review panelsCSO session World Bank, Washington DC and Cordaid Review Panel

December 2013: Final drafting position By Cordaid


2C. CORDAID UHC STUDY:METHODOLOGY (2)UHC in fragile and transition states

Questionnaire: main sections of investigation

• General conceptual understanding by important stakeholders

• Existing or developing UHC policies in more detail

• UHC implementation practice: practical programs & UHC dimensions (financial coverage, service delivery etc)

• UHC making a difference and role CSOs: new stakeholders, alliances, roles, effects, impacts?


2C. CORDAID UHC STUDY: METHODOLOGY (3)UHC in fragile and transition states

Interview key question areas

1. 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?

2. 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?

3. Drivers of UHC: Who are the perceived drivers of the UHC agenda so far and by whom is this agenda 'owned'?

4. 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?

5. 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?


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?


3. FIRST OBSERVATIONS


3. CORDAID UHC STUDY: FIRST OBSERVATIONS FROM LITERATURE REVIEW


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)


3B. CORDAID UHC STUDYFIRST OBSERVATIONS FROM LITERATURE SURVEY


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.


3C. CORDAID UHC STUDYFIRST OBSERVATIONS FROM THE INTERVIEWS


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


3C. CORDAID UHC STUDYFIRST OBSERVATIONS FROM THE INTERVIEWS (2)


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


3C. CORDAID UHC STUDY: FIRST OBSERVATIONS FROM THE INTERVIEWS (3)


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 exploredand 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


3C. CORDAID UHC STUDY: FIRST OBSERVATIONS FROM THE INTERVIEWS (4)


• 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


3C. CORDAID UHC STUDY:FIRST OBSERVATIONS FROM THE INTERVIEWS (5)


• 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

SPECIFIC PATHWAYS TO UHC IN FRAGILE STATES OR SPECIFIC PREREQUISITES?


6. THREE KEY ISSUES FOR

PANELDISCUSSION


6. THREE SETS OF QUESTIONS FOR PANEL


1. 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?

2. 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?


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FOR MORE INFORMATION PLEASE CONTACT:

REMCO VAN DER VEENDIRECTOR HEALTHCARE

E: [email protected]

mailto:[email protected]

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