Innovation in health financing doesn't mean forgetting the basics
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Version 0 of 1. Governments are issuing inspiring declarations of intent to provide health coverage for all citizens. Development partners are promising to back their efforts and Universal Health Coverage (UHC) has made it on to the shortlist for adoption as a Sustainable Development Goal. This should be good news for the world’s poor. Ultimately UHC is about ensuring that all citizens have access to accessible, affordable, quality health provision, regardless of their wealth, gender or other circumstances. We are, however, a long way from this target. Every day 800 women die during pregnancy or childbirth, while 8,000 new born babies die during their first month of life. Each year 100 million people are pushed into poverty by health costs. Finance is at the heart of the problem. Governments too often spend too little of their limited resources on health, and allocate scarce resources in an inefficient and inequitable manner. The World Health Organisation recommends that for a developing country to provide a basic package of essential services it must spend at least US$34 per capita, per annum. In 2012, twenty-two countries across Africa spent less than $50 per capita, per annum but there were eight countries that spent less than $25 per capita. The result is limited coverage and poor quality services that people have to pay for when they fall ill. Around two-thirds of health spending takes the form of out-of-pocket payments – and no money means no treatment. So, if finance is at the heart of the problem, what can be done? In the first instance, governments can take a critical look at how their health systems are financed to deliver the desired outcomes, and assess options for the future. There are a number of key principles that can be applied in this regard: • Understand the inputs, demographic trends, outputs and outcomes of the system that is being addressed; • Analyse options from the perspective of three basic principles of public finance: revenue collection, risk pooling, and allocation of revenues across a range of services. Healthcare financing reform implies introducing changes to one or more of these key functions of financing. • Guide financing decisions by taking into account the following criteria: - Is the mechanism (e.g. government financed, social health insurance, private health insurance and/or community-based health insurance) sustainable and feasible? - Does the mechanism pool risks and ensure financial protection? - Does it lead to greater efficiency in revenue collection and allocation? - Will its application enhance equity in financing and access to services? • Take a medium-to-long-term perspective, and ensure political and institutional factors are at the forefront of any assessment. Application of this approach is not new – policymakers within Ministries of Health and central government make macro level financial decisions to steer their health systems to deliver. Yet much of recent debate is focused on ‘new’ financing models (e.g. results based financing), and the degree of risk sharing between the public and private sectors. The debate has moved away from a holistic view of the sector, which analysed it within a sound macroeconomic framework. The ‘new’ hot topic results based financing (RBF) for health refers to any programme that transfers money or goods to either patients when they take health-related actions (such as having their children immunised) or to healthcare providers, when they achieve agreed performance targets (such as immunising a certain percentage of children in a given area). Crown Agents with HERA, is currently responsible for scaling up a RBF model across 42 districts in Zimbabwe, in close partnership with the Ministry of Health. The programme hopes to deliver improved quality, access and utilisation of primary and maternal, newborn and child health services. Evidence suggests that RBF programmes increase utilisation of services, but results are ambiguous as to how it affects health system measures such as quality, efficiency and outcomes. Implementing RBF alone may not deliver improvement in all health outputs or outcomes. It would be folly to consider any new innovation as the silver bullet to strengthening health systems. Instead we must continue to be guided by the principles of health financing and then consider new approaches. Undoubtedly taking a holistic view – technical, institutional and political - may be more onerous to measure, but without doing so we are less likely to see sustainable, long-term change. Jo Kemp is Crown Agents Practice Lead for Governance and State Building. Content on this page is paid for and provided by Crown Agents sponsor of the Guardian Global Development Professionals Network. |