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Health financing in post conflict settings

ReBUILD for Resilience
Jun. 14, 2016
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Health financing in post conflict settings

  1. Funded by Health financing in post conflict settings  Barbara McPake  Nossal Institute for Global Health  School of Population and Global Health  University of Melbourne
  2. Funded by Health financing debate in LMICs - summary of main issues • Since late 1980s, debate about the mechanisms by which funds flow from individuals and households to health service providers • taxation system - can fund use of public or private health providers • insurance systems - public and private • out-of-pocket payments - in public and private sectors • Clear consensus from a body of research that out-of-pocket payments significantly deter use of health care where important • Further conclusion that out of pocket payment (% in total health financing) and ‘catastrophic’ payment (incidence) strongly correlated
  3. Funded by • However, early evidence that ‘user fees plus quality improvement’ can maintain or increase use of health care • Raises tension between effects of intervention on demand and supply sides and their inter-relationships • Also raises issues of distribution of impacts - unlikely to be uniform change in use of care across population groups • Measures to target groups likely to be most negatively impacted - for example exemption systems have largely worked poorly though some experience of funded exemption has been better.
  4. Funded by • Generating sufficient resources to provide effective services may not be feasible through the tax system - either for economic or political reasons • Insurance mechanisms may better protect and stabilise health budgets • Public insurance systems operate similarly to tax - limits to fiscal space and politics constrain them • Private (voluntary) insurance systems exclude important population groups and increase inequities - although they may work well for large sections of the population • Community based insurance systems focused on poorer populations require subsidy; still often exclude the poorest
  5. Funded by • More attention in last decade to the need to support the ‘supply side’ while removing constraints to the ‘demand side’ • Recognises constraints to subsidy levels by focusing subsidies on target services - for example maternal and child health • Large numbers of countries have aimed to remove out of pocket payments while channelling additional resources to compensate for the loss of revenues • Mixed results - difficult to channel resources in ways that generate incentives for effective care delivery, but some successes
  6. Funded by ReBuild program • 6 year 6 partner research program funded by UK DFID • Partner institutions in UK, Cambodia, Uganda, Sierra Leone and Zimbabwe • ‘Path dependency’ idea at centre of design. What is possible with respect to policy development in post conflict period (short post conflict lens: N. Uganda and Zimbabwe)? What is the long term impact of changes made in the post conflict period (long post conflict lens: Cambodia and Sierra Leone)
  7. Funded by • Much stronger emphasis on the role of aid in these settings • manage transition from humanitarian to development aid • strengthening government stewardship and capacity • coordination • impact of Global Health Initiatives
  8. Funded by • Equity impacts of conflict create some unusual distributional contexts • Conflict may have ‘levelled down’ the economic situation of the population • May be strong regional patterns in distribution of impacts of conflict • Pre-conflict inequities may differ from post-conflict inequities and distributional questions may need to be considered from both perspectives • Free health care may be part of a post-conflict citizenship rights settlement
  9. Funded by • Context of health care provision - generally larger role for NGOs than in stable states • Provision transition expected to accompany aid transition and financing transition - shift of service delivery to public sector • But in practice, two main trends in health financing post- conflict are an increasing reliance on informal payments and donor funding
  10. Funded by • Strong parallels between user fee analysis in conflict affected settings and LMICs more generally • Greater emphasis on maintaining whatever is working and has survived the extremes of conflict conditions - often fee-paying NGO facilities • Afghanistan has provided a case study of successful exemption policy in a post-conflict setting • Cambodia has demonstrated positive impacts of health equity funds - funded exemption system • Rwanda has had most success with highly-subsidised community based insurance mechanism
  11. Funded by • Significant gaps in the literature • Weak literature methodologically - few papers proceed on the basis of clear methodology; piecemeal and small scale studies • Weak definitions of ‘fragile and conflict affected states’. Grouping highly diverse contexts facing very different challenges without clear basis of differentiation • Focus overwhelmingly on role of donors - much less attention to role of government policies • Emphasis on immediate post conflict period - few studies with longer perspective
  12. Funded by  ReBuild work in this area aimed to use our four case studies to strengthen the understanding of the impacts of health financing policies on poor people in post conflict contexts  4 very different contexts  Different sets of health financing policies and changes  Different data opportunities  2 case studies (Sierra Leone and Uganda) illustrate these issues – both unfinished work in progress.
  13. Funded by • Current cost recovery scheme introduced 2006 - flat fee charged for all health services except medicines for which full cost recovery fee applies • National guidelines to exempt children, adults over 60, pregnant/lactating women and disabled • Poorly implemented - group too large for resources at facility level; few in fact receive waivers
  14. Funded by • Free Health Care Initiative April 2010 • Children <5; pregnant and lactating women - free care - funded by government and donors • Range of health sector reforms - medicine supply management, human resources management • In first few months, use of health care by target groups increased sharply, but then gradually declined • Decline associated with shortages of medicines, informal charges
  15. Funded by • Study seeks to: • quantify impact of FHCI on child and maternal health service use and out of pocket payment • for children: a regression discontinuity design using 2011 Sierra Leone Integrated Household Survey (SLIHS) • for mothers: a time-trend adjusted before-after estimation approach using 2013 Sierra Leone Demographic and Health Survey (DHS)
  16. Funded by • SLIHS - nationally representative household survey 6800 households. Study uses subsample of children 0-120 months. Data on out of pocket payment, utilisation (used outpatient care in two week period preceding interview) in public and private facilities but excluding NGO facilities. • DHS - 16,658 women of reproductive age, most recent child birth over 5 year recall period and services received - information exists on births occurring before and after FHCI
  17. Funded by • Regression Discontinuity Design - exploits discontinuity in entitlement to free health care in relation to child age. If FHCI effective, a trend discontinuity at 60 months expected. • However, not all children < 60 months succeed in receiving free health care and some non-eligible children will have done, so => ‘fuzzy RDD’ • Time trend adjusted before-after estimation approach - 4 binary outcome variables compared - 4+ ANC visits; delivery in public facility; vit A supplementation up to 2 months; DPT+ vaccination in first year.
  18. Funded by Descriptive results: children
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  22. Funded byDescriptive results: women
  23. Funded by • Results statistically significant (though small) for simple comparison • After time trends and interaction terms included, no longer significant for facility births, delivery with skilled health workers or 4 ANC visits for all facilities • But significant for ANC, PNC, vit A and DPT+ significant for public facilities and fairly substantial for PNC, vit A and DPT+ • Effects larger and more significant in rural areas
  24. Funded by Before After
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  26. Funded by • No clear impact for children - might relate to lack of clarity about which children were exempted • DHS suggests increase in service use for children but may be longer term trend as there appears to be for women • Statistically significant increases in service use for women, substantial for some indicators and for rural areas • Overall disappointing impact may relate to continued costs, medicine shortages, targeting errors, insufficient supply side reforms
  27. Funded by Self-reported health, health utilisation, and food consumption in the post IDP camp period in Uganda • Fu-Min Tseng, Tim Ensor, Ijeoma Edoka, Robert Bataringaya, Sarah Ssali and Barbara McPake
  28. Funded by • Armed conflict Northern Uganda from early 1990s • By 2005, 2m internally displaced persons (IDPs) including 90- 95% of the population of Acholiland • Government declared it safe to leave camps in late 2006 • By 2009, IDP population had fallen to 450,000
  29. Funded by • As people return from camps… • reduction in exposure to camp specific risks including infectious disease, stresses of displacement, lack of life choices • access to health services may worsen as camp services inaccessible • need to re-establish livelihoods, planting cycles, housing and land rights - basic services including health may be secondary
  30. Funded by • Study investigates changes in health indicators, healthcare utilisation and food consumption of people living in districts highly affected by internal displacement over the period in which most returned • Analyses the Uganda National Household Surveys of 2005/6 and 2009/10 using difference in difference method • ‘Treatment group’ = 3 districts most exposed to conflict; excluded = 9 districts partially exposed to conflict; ‘control group’ = remaining districts not exposed to conflict • 5 outcomes - self-reported illness incidence in past 30 days; productive day loss caused by illness in last 30 days; visits to health facilities in the past 30 days; health expenditure in last 30 days; food consumption in the past 7 days
  31. Funded by • Descriptive statistics
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  33. Funded by • No significant evidence that self-reported health and frequency of healthcare utilisation changed after IDPs returned, but evidence of significant increase in food expenditure • Insignificant change in self-reported health may balance counteracting effects of fewer camp related risks but more limited availability of infrastructure and services. • Shift from formal private to informal care - probably reflects differing range of options.
  34. Funded by Overall conclusions • Literature on health financing in post conflict contexts is limited • Post conflict contexts are varied; policies diverse and data opportunities variable, so 4 case studies, even when fully complete will only add marginally • Many of the issues appear similar to those in other LMICs • Others specific to particular conflict related phenomena such as IDP return • Any level of generalisation will have to wait.
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