Universal Health Coverage: Frequently Asked QuestionsHFG Project
This brief answers several “frequently asked questions” (FAQ) on universal health coverage (UHC):
What is Universal Health Coverage (UHC)?
How does UHC align with USAID’s priorities?
How does UHC relate to broader goals for development, including the Sustainable Development Goals?
How is UHC measured?
What progress has been made towards UHC?
How does USAID support countries’ UHC efforts?
The FAQ accompanies Universal Health Coverage: An Annotated Bibliography, which presents resources that provide an overview of UHC and also delve into specific topics within UHC, such as measurement, health financing, and benefit plans. The bibliography also includes links to relevant websites that can provide additional resources.
Universal Health Coverage: Frequently Asked QuestionsHFG Project
This brief answers several “frequently asked questions” (FAQ) on universal health coverage (UHC):
What is Universal Health Coverage (UHC)?
How does UHC align with USAID’s priorities?
How does UHC relate to broader goals for development, including the Sustainable Development Goals?
How is UHC measured?
What progress has been made towards UHC?
How does USAID support countries’ UHC efforts?
The FAQ accompanies Universal Health Coverage: An Annotated Bibliography, which presents resources that provide an overview of UHC and also delve into specific topics within UHC, such as measurement, health financing, and benefit plans. The bibliography also includes links to relevant websites that can provide additional resources.
Implementing Pro-Poor Universal Health CoverageHFG Project
From The Lancet Global Health: Countries worldwide are embarking on health system reforms that move them closer to UHC, in many cases with a clear pro-poor focus. Along the way, there is a wealth of guidance on the technical aspects of UHC, such as designing health service packages and developing health financing systems. However, there is very little practical guidance on how to implement these policies.
Motivated by a shared interest in helping to close this information gap, a diverse international group of 21 practitioners and academics, including ministry of health officials and representatives of global health agencies and foundations, convened at The Rockefeller Foundation’s Bellagio Center for a three-day workshop from July 7–9, 2015.
The participants shared their experiences of implementing UHC and discussed the limited evidence on how to implement UHC, focusing on a set of seven key “how” questions from across five domains of UHC.
Universal health coverage (UHC)—ensuring that everyone has access to quality, affordable health services when needed—can be a vehicle for improved equity, health, financial well-being, and economic development. In its 2013 report, Global Health 2035, the Commission on Investing in Health (CIH) made the case that progressive (“pro-poor”) pathways towards UHC, which target the poor from the outset, are the most efficient way to achieve both improved health outcomes and increased financial protection (FP). Countries worldwide are now embarking on health system changes to move closer to achieving UHC, often with a clear pro-poor intent. While they can draw on guidance related to the technical aspects of UHC (the “what” of UHC), such as on service package design, there is less information on the “how” of UHC—that is, on how to maximize the chances of successful implementation.
Motivated by a shared interest in helping to close this information gap, a diverse international group of 21 practitioners and academics, including ministry of health officials and representatives of global health agencies and foundations, convened at The Rockefeller Foundation’s Bellagio Center for a three-day workshop from July 7–9, 2015. The participants shared their experiences of implementing UHC and discussed the limited evidence on how to implement UHC, focusing on a set of seven key “how” questions from across five domains of UHC.
Policy Brief: What Steps Are Countries Taking To Implement Pro-Poor Universal...HFG Project
Universal health coverage (UHC)—ensuring that everyone has access to quality, affordable health services when needed—can be a vehicle for improved equity, health, financial well-being, and economic development. In its 2013 report, Global Health 2035: A World Converging within a Generation, the Commission on Investing in Health made the case that pro-poor pathways towards UHC, which target the poor from the outset, are the most efficient way to achieve both improved health outcomes and increased financial protection (FP). Countries worldwide are now embarking on health system changes to move closer to achieving UHC, often with a clear pro-poor intent.
Much has been written about what steps countries have taken and are currently taking to: (1) set and expand guaranteed services, (2) develop health financing systems to fund guaranteed services and ensure FP, (3) ensure high-quality service availability and delivery, (4) improve governance and management of the health sector, and (5) strengthen other aspects of health systems to move closer to UHC. As background for a meeting on UHC implementation, held at the Rockefeller Foundation’s Bellagio Center, Italy, from 7–9 July 2015, we reviewed this body of literature, and conducted interviews with global UHC implementers and researchers. In this short policy brief, we synthesize the key messages from the literature and interviews.
Do Better Laws and Regulations Promote Universal Health Coverage? A Review of...HFG Project
The importance of policies, laws, and regulations (referred to collectively below as “policy instances”) as instruments to support progress towards Universal Health Coverage (UHC) in low- and middle-income countries cannot be understated. However, there has been insufficient focus in the literature on the role of these instruments, leading to a lack of evidence as to what constitutes a supportive legal environment that can consistently provide a strong basis for UHC reform processes. In this review, we explore how policies implemented in different country contexts have had an impact on their achievement of UHC goals.
In order to better differentiate the effect of various policy instances on the achievement of UHC goals, we developed a typology for policy instances and then ascribed the different aspects of governance to the instances identified in the literature, based on how they were designed and implemented. Finally, we considered the success of each policy instance identified, in terms of achieving intended UHC-related outcomes.
Governments may have political and process constraints on the number of policy instances they can design and implement in a period leading up to and during health sector reform. In terms of which health system component to focus such change on, we have more evidence for policy instances focused on health financing, given that designing effective financing mechanisms can shape the entire health
sector. Following this, policy instances that address human resources for health and supply chain management should be prioritized as they appear to have key strengthening effects on the provision of healthcare by increasing efficiency, equity, and quality.
This review of the evidence to date of governments’ policy-making experience highlights the importance of effective policy design and implementation with a clear orientation towards better governance, and in particular increased responsiveness and accountability.
Public Financial Management, Health Governance, and Health SystemsHFG Project
While the importance of governance in a health system is well recognized, there is an overall lack of evidence and understanding of the dynamics of how improved governance can influence health system performance and health outcomes. There is still considerable debate on which governance interventions are appropriate for different contexts. This lack of evidence can result in avoidance of health governance efforts or an over-reliance on a limited set of governance interventions. As development partners and governments are increasing their emphasis on improving accountability and transparency of health systems and strengthening country policies and institutions to move towards universal health coverage (UHC), the need of this evidence is ever rising.
To address this evidence gap, the USAID’s Office of Health Systems (USAID/GH/OHS), the World Health Organization (WHO), and the Health Finance and Governance (HFG) Project launched an initiative in September 2016 to ‘Marshall the Evidence’ on how governance contributes to health system performance and improves health outcomes.
The overall objective of the initiative was to increase awareness and understanding of the evidence of what works and why in how governance contributes to health system performance, and how the field of health governance is evolving at the country level. This report provides a synthesis of the findings across the four themes. This report presents the findings of the Public Financial Management.
Can community action improve equity for maternal health and how does it do soHFG Project
Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health.
This presentation discusses IHME's research in public financing of health in developing countries, including study design, findings, study limitations, and recommendations for governments and future research.
For more information please visit www.healthmetricsandevaluation.org
Essential Packages of Health Services in 24 Countries: Findings from a Cross-...HFG Project
Every country has finite resources for providing health care to its citizens. Policymakers are faced with a need to determine where to target limited resources. Explicitly prioritizing certain health care services and technologies can enable low- and middle-income countries to reach key development and public health goals (Glassman et al 2016). Certain health care interventions generate greater positive outcomes than others, which in turn lead to improvements in a country’s poverty, disease, or inequity burden. Once policymakers define priority services, they also must ensure that the services are available to all who need them.
The Role of Health Insurance in UHC: Learning from Ghana and EthiopiaHFG Project
USAID’s Health Finance and Governance (HFG) project works with partners around the world to support their progress towards universal health coverage (UHC). Protecting families and individuals from catastrophic health costs is one of the pillars of UHC. Health insurance is a key mechanism for providing financial protection. In this technical briefing, HFG shared lessons learned and technical insights from our work in piloting and scaling up community-based health insurance in Ethiopia and supporting Ghana’s National Health Insurance Authority to improve the financial sustainability of its National Health Insurance Scheme.
On Wednesday, March 2nd, the HFG project hosted a webinar featuring technical experts: Hailu Zelelew (Senior Associate/Health Economist, HFG Project), Chris Lovelace (Senior Health Governance Expert, HFG Project), and Jeanna Holtz (Health Insurance Specialist, HFG Project).
More:https://www.hfgproject.org/health-insurance-and-uhc-ghana-ethiopia/
Transforming Health Systems grants tackled four health systems concerns: stewardship and management, financing, information systems, and universal health care (UHC) policy and advocacy. In each target country, the grants provided transformative support to address key challenges.
Bangladesh faced serious constraints in its health sector workforce and weak health information systems. Thirty one grants helped provide training for health care professionals, assess and improve health information systems, and introduce UHC concepts to health sector stakeholders. The interventions increased awareness and commitment to UHC, contributed to improved and standardized medical education, and aided the development of integrated health information systems.
Ghana sought to build public sector capacity to steward and manage its mixed public-private health system. The program partnered with the International Finance Corporation, which assessed the private health sector. Thirteen grants subsequently sought to build capacity within the private sector unit in the Ministry of Health and to create a platform to facilitate engagement with the private sector. The interventions strengthened public sector capacity, increased policy dialogue around UHC, and strengthened the country’s National Health Insurance Scheme.
Rwanda’s health system reforms have sought to increase health service use, reduce out-of-pocket expenditures, and improve health indicators. Eleven grants focused particularly on building eHealth and technology platforms. The grants resulted in improved capacity to develop and implement sustainable eHealth solutions, as well as creation of a custom electronic medical records system and a Health Enterprise Architecture. Most grants included plans for sustainability beyond the life of the grant.
Vietnam wanted to find ways to expand coverage, improve financial protection, and reduce inequality, particularly through improving its provider payment system. Sixteen grants funded research to support reforms and design and test alternative capitation methods. The initiative built capacity in academic and research institutions, strengthened government capacity in health system management and planning, increased support for payment reform, and generated evidence to shape universal health insurance policies.
Presented at “Financial Protection and Improved Access to Health Care: Peer-to-Peer Learning Workshop Finding Solutions to Common Challenges” in Accra, Ghana, February 2016. To learn more, visit: https://www.hfgproject.org/ghana-uhc-workshop
Exploring New Sources of Revenue for Health: Filling the GapHFG Project
Resource Type: Brief
Authors: Jose Carlos Gutierrez, Sharon Nakhimovsky, Carlos Avila
Published: 04/01/2015
Resource Description:
In lower middle-income countries, many questions remain around how to scale up health systems to reach Universal Health Coverage. Where will the money come from; what financing mechanisms are available to policymakers; and what are the trade-offs that must be taken into account? This brief highlights the key questions and findings behind HFG’s technical report, “Domestic Innovative Financing for Health: Learning from Country Experience.” The report provides a framework for analyzing innovative options for raising additional revenue for health and reviews different countries’ experiences with each option. In the context of this report, “innovative” options are those that are new for a country and generate additional resources for the health sector. The successes and failures of these approaches provide food for thought as policymakers seek to leverage more resources for health. The full report is also available for download. - https://www.hfgproject.org/brief-exploring-new-sources-of-revenue-for-health/
Implementing Pro-Poor Universal Health CoverageHFG Project
From The Lancet Global Health: Countries worldwide are embarking on health system reforms that move them closer to UHC, in many cases with a clear pro-poor focus. Along the way, there is a wealth of guidance on the technical aspects of UHC, such as designing health service packages and developing health financing systems. However, there is very little practical guidance on how to implement these policies.
Motivated by a shared interest in helping to close this information gap, a diverse international group of 21 practitioners and academics, including ministry of health officials and representatives of global health agencies and foundations, convened at The Rockefeller Foundation’s Bellagio Center for a three-day workshop from July 7–9, 2015.
The participants shared their experiences of implementing UHC and discussed the limited evidence on how to implement UHC, focusing on a set of seven key “how” questions from across five domains of UHC.
Universal health coverage (UHC)—ensuring that everyone has access to quality, affordable health services when needed—can be a vehicle for improved equity, health, financial well-being, and economic development. In its 2013 report, Global Health 2035, the Commission on Investing in Health (CIH) made the case that progressive (“pro-poor”) pathways towards UHC, which target the poor from the outset, are the most efficient way to achieve both improved health outcomes and increased financial protection (FP). Countries worldwide are now embarking on health system changes to move closer to achieving UHC, often with a clear pro-poor intent. While they can draw on guidance related to the technical aspects of UHC (the “what” of UHC), such as on service package design, there is less information on the “how” of UHC—that is, on how to maximize the chances of successful implementation.
Motivated by a shared interest in helping to close this information gap, a diverse international group of 21 practitioners and academics, including ministry of health officials and representatives of global health agencies and foundations, convened at The Rockefeller Foundation’s Bellagio Center for a three-day workshop from July 7–9, 2015. The participants shared their experiences of implementing UHC and discussed the limited evidence on how to implement UHC, focusing on a set of seven key “how” questions from across five domains of UHC.
Policy Brief: What Steps Are Countries Taking To Implement Pro-Poor Universal...HFG Project
Universal health coverage (UHC)—ensuring that everyone has access to quality, affordable health services when needed—can be a vehicle for improved equity, health, financial well-being, and economic development. In its 2013 report, Global Health 2035: A World Converging within a Generation, the Commission on Investing in Health made the case that pro-poor pathways towards UHC, which target the poor from the outset, are the most efficient way to achieve both improved health outcomes and increased financial protection (FP). Countries worldwide are now embarking on health system changes to move closer to achieving UHC, often with a clear pro-poor intent.
Much has been written about what steps countries have taken and are currently taking to: (1) set and expand guaranteed services, (2) develop health financing systems to fund guaranteed services and ensure FP, (3) ensure high-quality service availability and delivery, (4) improve governance and management of the health sector, and (5) strengthen other aspects of health systems to move closer to UHC. As background for a meeting on UHC implementation, held at the Rockefeller Foundation’s Bellagio Center, Italy, from 7–9 July 2015, we reviewed this body of literature, and conducted interviews with global UHC implementers and researchers. In this short policy brief, we synthesize the key messages from the literature and interviews.
Do Better Laws and Regulations Promote Universal Health Coverage? A Review of...HFG Project
The importance of policies, laws, and regulations (referred to collectively below as “policy instances”) as instruments to support progress towards Universal Health Coverage (UHC) in low- and middle-income countries cannot be understated. However, there has been insufficient focus in the literature on the role of these instruments, leading to a lack of evidence as to what constitutes a supportive legal environment that can consistently provide a strong basis for UHC reform processes. In this review, we explore how policies implemented in different country contexts have had an impact on their achievement of UHC goals.
In order to better differentiate the effect of various policy instances on the achievement of UHC goals, we developed a typology for policy instances and then ascribed the different aspects of governance to the instances identified in the literature, based on how they were designed and implemented. Finally, we considered the success of each policy instance identified, in terms of achieving intended UHC-related outcomes.
Governments may have political and process constraints on the number of policy instances they can design and implement in a period leading up to and during health sector reform. In terms of which health system component to focus such change on, we have more evidence for policy instances focused on health financing, given that designing effective financing mechanisms can shape the entire health
sector. Following this, policy instances that address human resources for health and supply chain management should be prioritized as they appear to have key strengthening effects on the provision of healthcare by increasing efficiency, equity, and quality.
This review of the evidence to date of governments’ policy-making experience highlights the importance of effective policy design and implementation with a clear orientation towards better governance, and in particular increased responsiveness and accountability.
Public Financial Management, Health Governance, and Health SystemsHFG Project
While the importance of governance in a health system is well recognized, there is an overall lack of evidence and understanding of the dynamics of how improved governance can influence health system performance and health outcomes. There is still considerable debate on which governance interventions are appropriate for different contexts. This lack of evidence can result in avoidance of health governance efforts or an over-reliance on a limited set of governance interventions. As development partners and governments are increasing their emphasis on improving accountability and transparency of health systems and strengthening country policies and institutions to move towards universal health coverage (UHC), the need of this evidence is ever rising.
To address this evidence gap, the USAID’s Office of Health Systems (USAID/GH/OHS), the World Health Organization (WHO), and the Health Finance and Governance (HFG) Project launched an initiative in September 2016 to ‘Marshall the Evidence’ on how governance contributes to health system performance and improves health outcomes.
The overall objective of the initiative was to increase awareness and understanding of the evidence of what works and why in how governance contributes to health system performance, and how the field of health governance is evolving at the country level. This report provides a synthesis of the findings across the four themes. This report presents the findings of the Public Financial Management.
Can community action improve equity for maternal health and how does it do soHFG Project
Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health.
This presentation discusses IHME's research in public financing of health in developing countries, including study design, findings, study limitations, and recommendations for governments and future research.
For more information please visit www.healthmetricsandevaluation.org
Essential Packages of Health Services in 24 Countries: Findings from a Cross-...HFG Project
Every country has finite resources for providing health care to its citizens. Policymakers are faced with a need to determine where to target limited resources. Explicitly prioritizing certain health care services and technologies can enable low- and middle-income countries to reach key development and public health goals (Glassman et al 2016). Certain health care interventions generate greater positive outcomes than others, which in turn lead to improvements in a country’s poverty, disease, or inequity burden. Once policymakers define priority services, they also must ensure that the services are available to all who need them.
The Role of Health Insurance in UHC: Learning from Ghana and EthiopiaHFG Project
USAID’s Health Finance and Governance (HFG) project works with partners around the world to support their progress towards universal health coverage (UHC). Protecting families and individuals from catastrophic health costs is one of the pillars of UHC. Health insurance is a key mechanism for providing financial protection. In this technical briefing, HFG shared lessons learned and technical insights from our work in piloting and scaling up community-based health insurance in Ethiopia and supporting Ghana’s National Health Insurance Authority to improve the financial sustainability of its National Health Insurance Scheme.
On Wednesday, March 2nd, the HFG project hosted a webinar featuring technical experts: Hailu Zelelew (Senior Associate/Health Economist, HFG Project), Chris Lovelace (Senior Health Governance Expert, HFG Project), and Jeanna Holtz (Health Insurance Specialist, HFG Project).
More:https://www.hfgproject.org/health-insurance-and-uhc-ghana-ethiopia/
Transforming Health Systems grants tackled four health systems concerns: stewardship and management, financing, information systems, and universal health care (UHC) policy and advocacy. In each target country, the grants provided transformative support to address key challenges.
Bangladesh faced serious constraints in its health sector workforce and weak health information systems. Thirty one grants helped provide training for health care professionals, assess and improve health information systems, and introduce UHC concepts to health sector stakeholders. The interventions increased awareness and commitment to UHC, contributed to improved and standardized medical education, and aided the development of integrated health information systems.
Ghana sought to build public sector capacity to steward and manage its mixed public-private health system. The program partnered with the International Finance Corporation, which assessed the private health sector. Thirteen grants subsequently sought to build capacity within the private sector unit in the Ministry of Health and to create a platform to facilitate engagement with the private sector. The interventions strengthened public sector capacity, increased policy dialogue around UHC, and strengthened the country’s National Health Insurance Scheme.
Rwanda’s health system reforms have sought to increase health service use, reduce out-of-pocket expenditures, and improve health indicators. Eleven grants focused particularly on building eHealth and technology platforms. The grants resulted in improved capacity to develop and implement sustainable eHealth solutions, as well as creation of a custom electronic medical records system and a Health Enterprise Architecture. Most grants included plans for sustainability beyond the life of the grant.
Vietnam wanted to find ways to expand coverage, improve financial protection, and reduce inequality, particularly through improving its provider payment system. Sixteen grants funded research to support reforms and design and test alternative capitation methods. The initiative built capacity in academic and research institutions, strengthened government capacity in health system management and planning, increased support for payment reform, and generated evidence to shape universal health insurance policies.
Presented at “Financial Protection and Improved Access to Health Care: Peer-to-Peer Learning Workshop Finding Solutions to Common Challenges” in Accra, Ghana, February 2016. To learn more, visit: https://www.hfgproject.org/ghana-uhc-workshop
Exploring New Sources of Revenue for Health: Filling the GapHFG Project
Resource Type: Brief
Authors: Jose Carlos Gutierrez, Sharon Nakhimovsky, Carlos Avila
Published: 04/01/2015
Resource Description:
In lower middle-income countries, many questions remain around how to scale up health systems to reach Universal Health Coverage. Where will the money come from; what financing mechanisms are available to policymakers; and what are the trade-offs that must be taken into account? This brief highlights the key questions and findings behind HFG’s technical report, “Domestic Innovative Financing for Health: Learning from Country Experience.” The report provides a framework for analyzing innovative options for raising additional revenue for health and reviews different countries’ experiences with each option. In the context of this report, “innovative” options are those that are new for a country and generate additional resources for the health sector. The successes and failures of these approaches provide food for thought as policymakers seek to leverage more resources for health. The full report is also available for download. - https://www.hfgproject.org/brief-exploring-new-sources-of-revenue-for-health/
The purpose of this presentation is to equip audiences with the ability to:
Define universal health coverage (UHC) and understand the basic tenets of UHC
Identify how UHC fits in USAID’s health and poverty reduction strategies
Effectively communicate to country stakeholders how USAID can support a country’s progress towards UHC
Identify relevant UHC resources within the Office of Health Systems and USAID
The presentation is part of the “UHC Toolkit” and accompanies Universal Health Coverage: An Annotated Bibliography, and Universal Health Coverage: Frequently Asked Questions.
Monitoring progress towards universal health coverage at country and global l...The Rockefeller Foundation
A movement towards universal health coverage (UHC) – ensuring that everyone who needs health services is able to get them, without undue financial hardship – has been growing across the globe (1). This has led to a sharp increase in the demand for expertise, evidence and measures of progress and a push to make UHC one of the goals of the post-2015 development agenda (2). This paper proposes a framework for tracking country and global progress towards UHC; its aim is to inform and guide these discussions and assessment of both aggregate and equitable coverage of essential health services as well as financial protection. Monitoring progress towards these two components of UHC will be complementary and critical to achieving desirable health outcome goals, such as ending preventable deaths and promoting healthy life expectancy and also reducing poverty and protecting household incomes.
This paper was written jointly by the World Health Organization (WHO) and The World Bank Group on the basis of consultations and discussions with country representatives, technical experts and global health and development partners (3). A draft of this paper was posted online and circulated widely for consultation between December 2013 and February 2014. Nearly 70 submissions were received from countries, development partners, civil society, academics and other interested stakeholders. The feedback was synthesized and reviewed at a meeting of country and global experts in Bellagio, Italy, in March 2014 (4). The paper was modified to reflect the views emerging from these consultations.
Health financing in bangladesh why changes in public financial management rul...HFG Project
Bangladesh has achieved remarkable improvement in health indicators since its independence in 1971, despite poor economic conditions. It achieved Millennium Development Goal 4 on child mortality and progressed substantially toward Goal 5 on maternal mortality, even with health system bottlenecks such as weak governance, insufficient health financing, and limited capacity to address local need. In a country with a history of adopting low-cost strategies with high health impact, focusing on primary health care—even with limited resources—was the single most important factor in these achievements.
Follow the Money: Making the Most of Limited Health ResourcesHFG Project
Worldwide, health systems are being asked to do more with less. In many countries, donor funds have stagnated or are declining. This sharp decline could have broad implications for the health sector— particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. New and emerging threats, such as Zika and Ebola, are also testing weak and fragile health systems, such as those in Guinea and Liberia. And costly noncommunicable diseases, like diabetes and cancers, are on the rise in low- and middle-income countries (LMICs).
With the end of the MDGs and start of the new SDGS, momentum is growing for countries around the world to pursue Universal Health Coverage (UHC) reforms and to expand affordable access to health care services, without risk of financial hardship, while facing real resource constraints in the aftermath of the global economic crisis.
In short, countries need to make their limited health resources go a long way. It is a financing challenge as well as a governance one. Countries cannot manage what they cannot measure. Countries need to measure their health spending – know where the money comes from, how much is spent and where, and how it can be spent more efficiently and equitably.
Policymakers can influence public and private health spending to improve efficiency, quality, equity, and expand access to life-saving health services. To succeed, however, governments need evidence around their health financing landscape. More and more, policymakers are appreciating the value of health resource tracking –that is, a range of methods, data collection initiatives, and estimation tools aimed at measuring the flow of funds to and through the health system.
Follow the Money: Making the Most of Limited Health ResourcesHFG Project
Worldwide, health systems are being asked to do more with less. In many countries, donor funds have stagnated or are declining. This sharp decline could have broad implications for the health sector— particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. New and emerging threats, such as Zika and Ebola, are also testing weak and fragile health systems, such as those in Guinea and Liberia. And costly noncommunicable diseases, like diabetes and cancers, are on the rise in low- and middle-income countries (LMICs).
With the end of the MDGs and start of the new SDGS, momentum is growing for countries around the world to pursue Universal Health Coverage (UHC) reforms and to expand affordable access to health care services, without risk of financial hardship, while facing real resource constraints in the aftermath of the global economic crisis.
In short, countries need to make their limited health resources go a long way. It is a financing challenge as well as a governance one. Countries cannot manage what they cannot measure. Countries need to measure their health spending – know where the money comes from, how much is spent and where, and how it can be spent more efficiently and equitably.
Capital Investment in Health Systems: What is the latest thinking?HFG Project
Capital investment in health typically refers to large expenditures in construction of hospitals and other facilities, investment in diagnostic and treatment technologies, and information technology platforms. These investments are characterized by their longevity and they are critical to efforts to improve healthcare quality and efficiency. Contrary to developed countries where there is well documented experience on capital investment in the health sector, including use of public private partnerships for the investment; there is little evidence on capital investment in health from low and middle income countries.
This work was undertaken to add to the HFG’s knowledge and learning strategy by clarifying what good practice guidance exists in capital benchmark in LMICs health sectors, as well as the HFG project’s experience in the area. This brief will be of value to all those interested in the planning and financing the capital investment in the health sector. This includes politicians, planners, managers, health professionals, architects, designers, and researchers in both the public and private sectors.
HFG Rapid Assessment of TB Payment and PFM Systems in the Philippines: Lesson...HFG Project
In the Philippines, there are roughly 290,000 new TB cases per year (WHO, 2016). Meanwhile, donor funding for TB has declined, health care costs are rising, and out-of-pocket spending accounts for roughly two-thirds of national TB expenditures. The Philippines needs to identify mechanisms to improve the efficiency of TB spending (i.e., mechanisms for spending money wisely). In the short term, this may mean finding ways to improve outputs—such as access, use of services, and quality—for a given level of spending on TB. In the long term, the Philippines and countries facing similar challenges may be interested in finding ways to achieve better outputs with fewer resources.
The Philippines was the subject of one of several country case studies linking strategic TB purchasing with improved efficiency and better outcomes. In April 2016, HFG conducted a brief but in-depth assessment of health purchasing/provider payment and PFM systems in the Philippines, to identify rigidities and barriers.
Developing Haiti’s First Health Financing StrategyHFG Project
The Ministry has an approved National Health Policy, known as the Politique Nationale de Santé, which addresses “what” is to be done. In addition, the Ministry is developing a National Health Plan that lays out “how” the National Health Policy will be made operational. However, the Ministry of Health does not yet have a national health financing strategy that outlines “where” resources will come from and “how” they will be used to achieve the country’s health objectives.
To bridge this important gap, the HFG project is working with the Planning and Evaluation Unit of the Ministry of Health to develop a national health financing strategy that will include an operational plan consisting of specific activities, timelines, and an overall health budget. The strategy will focus on the three core functions of health financing: mobilization of resources; pooling of risks and financial protection; and purchasing and provider payment. A strategy mapping out these core health financing functions will enable Haiti to raise the necessary resources, better protect people from the financial consequences of ill health, and make optimum use of resources to achieve the National Health Plan’s vision.
The health financing strategy will serve as a road map, particularly when it is combined with data from the second National Health Accounts, which the HFG project is also supporting, and a fully costed National Health Plan. Together, they will provide strong evidence and powerful justification for increased health financing in the future to improve Haiti’s health outcomes.
Linkages Between the Essential Health Services Package and Government-Sponsor...HFG Project
Priority setting is a key function of health systems that seek to achieve universal health coverage. The Essential Health Services Package (EHSP) explicitly prioritizes certain services; government-sponsored health benefit plans implicitly prioritize others. To gain insights into the purpose, policy objectives, and governance of the EPHS and dominant health benefit plans in Ethiopia, we conducted a case study in 2016. Methods included a desk review of relevant documents and qualitative analysis of 15 key informant interviews of leading health finance experts in Addis Ababa. All data were coded and analyzed using a thematic inductive framework.
Using Evidence to Design Health Benefit Plans for Stronger Health Systems: Le...HFG Project
Low- and middle-income country governments face competing health priorities as they try to increase their populations’ access to affordable healthcare with limited resources. Faced with difficult choices, how can governments align their spending with health system objectives? One common policy instrument governments are using is the health benefit plan (HBP), defined here as a pre-determined, publicly managed list of guaranteed health services. Based on country experiences, the authors of this report argue that using evidence improves the potential for HBPs to achieve and balance countries’ objectives for equity, efficiency, financial protection, and sustainability in the health sector.
Governments using—or considering—HBPs as part of their pathway to UHC are faced with complex questions as they prepare to design new HBPs or update existing ones to address technological, epidemiological, economic, or other changes. This report is intended to serve as a resource for these governments. Through a review of 25 countries examining the types of evidence used to design and update HBPs, this report identifies actionable lessons for designing HBPs that advance health systems objectives in a sustainable way. More: www.hfgproject.org and https://www.hfgproject.org/using-evidence-health-benefit-plans/
Improving Efficiency to Achieve Health System Goals in Botswana: Background P...HFG Project
Health outcomes have improved in Botswana over the last few decades. These successes have come at the same time as overall macroeconomic growth, with annual Gross Domestic Product (GDP) growth averaging around 6 percent between 2010 and 2015 (IMF 2015), and Human Development Index ranking above the regional average. These improvements originate in a strong health service delivery system. In 2008, Botswana’s public health system included 338 health posts and 277 health clinics, sufficient to ensure that at least 80 percent of the population has coverage of essential, high-impact services. Management of these services was initially done by the Ministry of Local Government but has been transferred to district health teams under the Ministry of Health (MOH). As of 2008, Botswana’s public health system also had 17 primary hospitals, 14 district hospitals, two referral hospitals, and one mental health hospital; these hospitals are managed by the central government.
Understanding Health Accounts: A Primer for PolicymakersHFG Project
An update of the 2003 brief, this new primer provides an introduction to Health Accounts, the framework (System of Health Accounts 2011 or SHA 2011), and key steps involved in conducting Health Accounts exercises using SHA 2011 with particular emphasis on how policymakers can get involved to facilitate the process. The primer also includes country experiences illustrating show how Health Accounts data can be used for policy purposes, with specific attention to the importance of institutionalizing Health Accounts so that it may serve as an ongoing resource to policymakers.
ZGB - The Role of Generative AI in Government transformation.pdfSaeed Al Dhaheri
This keynote was presented during the the 7th edition of the UAE Hackathon 2024. It highlights the role of AI and Generative AI in addressing government transformation to achieve zero government bureaucracy
Many ways to support street children.pptxSERUDS INDIA
By raising awareness, providing support, advocating for change, and offering assistance to children in need, individuals can play a crucial role in improving the lives of street children and helping them realize their full potential
Donate Us
https://serudsindia.org/how-individuals-can-support-street-children-in-india/
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Presentation by Jared Jageler, David Adler, Noelia Duchovny, and Evan Herrnstadt, analysts in CBO’s Microeconomic Studies and Health Analysis Divisions, at the Association of Environmental and Resource Economists Summer Conference.
Russian anarchist and anti-war movement in the third year of full-scale warAntti Rautiainen
Anarchist group ANA Regensburg hosted my online-presentation on 16th of May 2024, in which I discussed tactics of anti-war activism in Russia, and reasons why the anti-war movement has not been able to make an impact to change the course of events yet. Cases of anarchists repressed for anti-war activities are presented, as well as strategies of support for political prisoners, and modest successes in supporting their struggles.
Thumbnail picture is by MediaZona, you may read their report on anti-war arson attacks in Russia here: https://en.zona.media/article/2022/10/13/burn-map
Links:
Autonomous Action
http://Avtonom.org
Anarchist Black Cross Moscow
http://Avtonom.org/abc
Solidarity Zone
https://t.me/solidarity_zone
Memorial
https://memopzk.org/, https://t.me/pzk_memorial
OVD-Info
https://en.ovdinfo.org/antiwar-ovd-info-guide
RosUznik
https://rosuznik.org/
Uznik Online
http://uznikonline.tilda.ws/
Russian Reader
https://therussianreader.com/
ABC Irkutsk
https://abc38.noblogs.org/
Send mail to prisoners from abroad:
http://Prisonmail.online
YouTube: https://youtu.be/c5nSOdU48O8
Spotify: https://podcasters.spotify.com/pod/show/libertarianlifecoach/episodes/Russian-anarchist-and-anti-war-movement-in-the-third-year-of-full-scale-war-e2k8ai4
Canadian Immigration Tracker March 2024 - Key SlidesAndrew Griffith
Highlights
Permanent Residents decrease along with percentage of TR2PR decline to 52 percent of all Permanent Residents.
March asylum claim data not issued as of May 27 (unusually late). Irregular arrivals remain very small.
Study permit applications experiencing sharp decrease as a result of announced caps over 50 percent compared to February.
Citizenship numbers remain stable.
Slide 3 has the overall numbers and change.
Up the Ratios Bylaws - a Comprehensive Process of Our Organizationuptheratios
Up the Ratios is a non-profit organization dedicated to bridging the gap in STEM education for underprivileged students by providing free, high-quality learning opportunities in robotics and other STEM fields. Our mission is to empower the next generation of innovators, thinkers, and problem-solvers by offering a range of educational programs that foster curiosity, creativity, and critical thinking.
At Up the Ratios, we believe that every student, regardless of their socio-economic background, should have access to the tools and knowledge needed to succeed in today's technology-driven world. To achieve this, we host a variety of free classes, workshops, summer camps, and live lectures tailored to students from underserved communities. Our programs are designed to be engaging and hands-on, allowing students to explore the exciting world of robotics and STEM through practical, real-world applications.
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In addition to our local programs, Up the Ratios is committed to making a global impact. We take donations of new and gently used robotics parts, which we then distribute to students and educational institutions in other countries. These donations help ensure that young learners worldwide have the resources they need to explore and excel in STEM fields. By supporting education in this way, we aim to nurture a global community of future leaders and innovators.
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We are proud of the positive impact we've had on the lives of countless students, many of whom have gone on to pursue higher education and careers in STEM. By providing these young minds with the tools and opportunities they need to succeed, we are not only changing their futures but also contributing to the advancement of technology and innovation on a broader scale.
A process server is a authorized person for delivering legal documents, such as summons, complaints, subpoenas, and other court papers, to peoples involved in legal proceedings.
2. Research Article
Emerging Lessons from the Development of National
Health Financing Strategies in Eight Developing
Countries
Jonathan Cali1,
*, Marty Makinen2
, and Yann Derriennic 1
1
International Development Division, Abt Associates, Rockville, MD, USA
2
Results for Development Institute, Washington, DC, USA
CONTENTS
Introduction
Methods
Discussion
Conclusion
References
Abstract—As countries advance economically, they are increasingly
under pressure to mobilize and properly manage domestic resources
to provide affordable health care for their citizens. The World Health
Organization and international donors have encouraged countries to
develop a health financing strategy (HFS) to plan how to best achieve
these objectives. This article highlights lessons and considerations for
countries developing HFSs and for donors supporting the process, in
the areas of data use, cross-country learning, evaluation, leadership
involvement, and stakeholder management. This article’s review of
the United States Agency for International Development (USAID)-
supported Health Finance and Governance (HFG) and Health System
Strengthening Plus projects’ experiences assisting eight countries with
HFS development concludes that the HFS development process
generates demand among low- and middle-income country policy
makers for health financing data and that countries that complete
HFSs accept that basing a strategy on imperfect data is better than not
having a strategy. The article also concludes that cross-country
learning, through guided study trips and reviews of other health
systems and HFS processes, is paramount for developing an HFS and
that most countries have not included monitoring and evaluation plans
in their HFSs. Finally, in HFG’s experience, countries developing
HFSs have been successful in fostering ownership among a broad
coalition of stakeholders but diverge in their approaches to involving
political leaders in detailed technical debates about health financing
reform. These lessons and challenges, based on real-world
experiences, can help low- and middle-income countries to develop
politically feasible HFSs that promote financial sustainability of the
health sector, protect people from burdensome health care costs,
improve efficiency, and advance universal health coverage.
INTRODUCTION
Health care costs have been rising globally as the burden of
noncommunicable diseases increases, infectious diseases
persist, and new, costly treatments are developed. With rising
Keywords: cross-country learning, health financing reform, health financing
strategy, policy development process, universal health coverage
Received 15 November 2017; revised 26 January 2018; accepted 3 February
2018.
*Correspondence to: Jonathan Cali; Email: Jonathan_Cali@abtassoc.com
Ó 2018 Jonathan Cali, Marty Makinen, and Yann Derriennic.
This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
136
Health Systems & Reform, 4(2):136–145, 2018
Published with license by Taylor & Francis on behalf of the USAID’s Health Finance and Governance Project
ISSN: 2328-8604 print / 2328-8620 online
DOI: 10.1080/23288604.2018.1438058
3. incomes, populations want access to better quality, afford-
able health services and to be protected from the need to
make “catastrophic” payments for care. Thus, governments
are under pressure to raise additional domestic resources for
health, to ensure that their populations are protected from
impoverishing out-of-pocket payments, and to improve the
efficiency of health spending in order to do more with avail-
able funding.
The rise in health care demand and costs and the pressure on
the government to respond are not new trends. In 1995, the
World Bank compiled and analyzed health care financing case
studies to share the lessons learned from Asian, North Ameri-
can, and European countries’ attempts over many decades to
finance health care for their populations.1
The publication notes
that health financing policies in these countries evolved gradu-
ally over the years and were rarely explicitly reexamined unless
a new health insurance program was to be introduced. It also
states that developing countries had almost never engaged in
strategic planning for health financing.1
In presenting a frame-
work for health sector reforms, Roberts and colleagues advise
that health reforms, including financing reforms, should
address challenges comprehensively and that the process
should involve a broad group of stakeholders, be guided by a
change team, imitate the positive experiences of other coun-
tries, and be informed by evidence but not to expect that all evi-
dence desired will be available.2
Carrin and colleagues
developed a framework specifically for developing financing
policy for universal health coverage.3
They acknowledge the
need to make “a multitude of interrelated decisions” to develop
such a policy but do not explicitly call for the development of
structured health financing strategies.3
Kutzin proposes a
framework for health financing policy making for European
countries, especially those undergoing economic transition,4
and Kutzin and colleagues share lessons from implementing
such reforms.5
Building on this earlier work, the World Health Organ-
ization’s (WHO) 2010 World Health Report on financing for
universal coverage encourages low- and middle-income
countries to engage in structured policy processes to develop
health financing strategies (HFSs), often with the support of
the WHO and other international development assistance
partners.6
HFSs generally define how resources should be
collected, pooled, and spent to advance toward universal
health coverage. The WHO published its first detailed guid-
ance for developing HFSs in 2017.7
According to the WHO,
an HFS should be based on a diagnosis of a health system’s
current challenges to achieving its goals, focus on the entire
population rather than a subset, identify detailed objectives
and actions to overcome current challenges, and include an
evaluation strategy. Ultimately, an effective strategy should
increase people’s ability to use health care based on need,
protect the population from financial ruin, and improve the
quality of health care.7
In the years between the 2010 World Health Report6
and the
release of the WHO’s guidance in 2017,7
international devel-
opment partners have nudged politicians and health officials in
many low- and middle-income countries to develop strategies
for financing their health care systems. However, there have
been few attempts to extract cross-country learnings from the
experiences of developing such strategies. Since 2010, United
States Agency for International Development (USAID)-
financed projects have supported the development of HFSs in
eight countries (Bangladesh, Botswana, Cambodia, Haiti,
Nigeria, Senegal, Tanzania, and Vietnam), with the Health
Financing and Governance Project (HFG) supporting seven
countries and Health Systems Strengthening Plus (HSSC) sup-
porting Senegal. Given that these HFS development processes
were initiated before the release of the WHO’s guidance in
2017, each government took a somewhat different approach to
developing their HFSs. This article analyzes these eight
national experiences and highlights the lessons and challenges
derived from their HFS development processes. Most of the
HFSs discussed in this article are still in the development
phase, were completed but not formally approved, or were
only recently approved. Acknowledging that successful imple-
mentation of the HFSs and eventual impact on health and eco-
nomic outcomes are the ultimate means of assessing HFSs, the
implementation and impact of the HFSs discussed here will not
be observable for several years. Therefore, providing guidance
on implementation of HFSs or evaluating them based on imple-
mentation and outcomes is beyond the scope of this article.
Rather, this article documents the experiences of these eight
countries in drafting their HFSs and offers observations con-
cerning approaches that worked well and those that might
require additional thought and consideration. These lessons
can serve as valuable guides for the many countries that are
currently in the process of developing an HFS or will be updat-
ing one in the future. Furthermore, this article provides infor-
mation based on country experiences that can be incorporated
into future guidance on HFS development.
An HFS, if implemented, could have far-reaching impacts
on the health sector, economy, and lives of ordinary citizens.
As a result, the HFS development process is a delicate art of
balancing stakeholder interests, making decisions with
incomplete information, and determining when and how to
communicate key technical recommendations and proposed
policy choices for health financing to political decision mak-
ers. The lessons and challenges highlighted in this article can
assist countries in their efforts to produce HFSs that advance
universal health coverage while being politically acceptable
Cali et al.: Emerging Lessons from National Health Financing Strategies 137
4. and can allow development agencies and international agen-
cies to ensure that the guidance they provide to countries is
as relevant as possible.
METHODS
HFG is a USAID-funded global health systems–strengthening
project assisting more than 30 countries to improve health out-
comes by improving financing, governance, and management
of their health systems.8
HSSC has similar objectives in Sene-
gal. The USAID-financed projects have provided varying
degrees and types of technical assistance to the HFS develop-
ment process in eight countries. This assistance, conducted in
close collaboration with national policy makers, has included
facilitating stakeholder workshops, conducting research and
analysis, providing training sessions on health financing con-
cepts, advising ministries of health and finance on process
design, and arranging cross-country sharing of information
and lessons, as demonstrated in Table 1.
This article presents lessons gleaned from USAID-
financed projects’ experience interacting with the HFS
processes and working closely with policy makers in
these countries. The authors adapted recommendations
from the WHO’s reference guide for developing health
financing strategies7
to create a framework for analyzing
eight HFS processes based on firsthand observations and
supplemented these observations with a document review
and interviews and discussions with other HFG staff. The
framework for this article, shown in Table 2, facilitates
the analysis of the HFSs’ composition based on their
inclusion of six ideal attributes and their processes’
adherence to four “good practices” for managing and
facilitating HFS development.7
Review of Eight Health Financing Strategies
HFG’s review, summarized in Table 3, identified several
similarities across eight countries in the composition of their
health financing strategies and in the HFS development pro-
cess. Although the HFS development processes were largely
in line with the good practices, one of the six ideal attributes
was absent from all of the HFSs reviewed. This section high-
lights some of the similarities and differences among the
HFSs and their alignment (or misalignment) with the ideal
attributes and good practices for HFS development.
Composition of Health Financing Strategies
Ideally, all HFSs should be informed by a diagnosis of a
country’s current health financing situation and
Country HFG/Consortium Role Other Partners
Bangladesh Facilitated technical working groups, edited document,
facilitated completion workshop, facilitated dissemination
World Bank
Botswana Facilitated technical working group; provided capacity building
and technical assistance on health insurance, benefits
package design, and provider payment; conducted landscape
analysis, NHA, efficiency review
WHO, Joint United Nations Programme on HIV and AIDS
Cambodia Provided capacity building for working group International Labor Organization, Deutsche Gesellschaft f€ur
Internationale Zusammenarbeit (GIZ) GmbH, Japanese
International Cooperation Agency, WHO, World Bank
Haiti Conducted situation analysis, facilitated international
conference on health financing, provided capacity building
of technical drafting committee, facilitated drafting of
document
World Bank, Pan American Health Organization/WHO
Nigeria Developed a governance framework and narrative for the policy
that outlined which institutions would be responsible for
implementation, developed theory of change of strategy
WHO, World Bank
Tanzania Specific technical assistance Providing for Health, Deutsche Gesellschaft f€ur
Internationale Zusammenarbeit (GIZ) GmbH, WHO,
USAID Health Policy Project
Senegal Provided input in design and technical content for HFS
development process
WHO, Japanese International Cooperation Agency, World
Bank
Vietnam Supported planning for HFS implementation WHO, World Bank, European Union, Japanese International
Cooperation Agency
TABLE 1. HFG and Other Development Partners’ Roles in HFS Development
138 Health Systems & Reform, Vol. 4 (2018), No. 2
5. performance relative to health financing objectives, and
the WHO has developed a guide to facilitate this.9
Con-
ducting a situational analysis was a critical starting point
for HFS development in all eight countries reviewed,
regardless of the quantity or quality of existing health
financing data. The most recent National Health Account
(NHA) information was the most common data source
used to inform the situational analysis across the eight
countries. Countries also used public expenditure reviews,
household surveys such as demographic and health sur-
veys and living standards surveys, fiscal space analyses,
and estimation of current and future costs and revenues.
Botswana, Cambodia, Senegal, and Tanzania included
examples from international experience or comparisons to
peer countries in their situation analyses. Overall, the
countries analyzed their current situation and, with one
exception, did not let the absence of up-to-date data keep
them from advancing with the development of a strategy.
The eight countries studied were able to establish specific
objectives for their HFS documents, providing a snapshot of
some of the most pressing health financing–related concerns
and priorities in low- and middle-income countries. The
most common HFS objective related to financial sustainabil-
ity of the health system, especially in the context of declining
donor funding. Six of the eight countries (Cambodia and
Haiti are the exceptions) included objectives that related to
increased pooling, such as an expansion of national health
insurance, to provide financial protection or reduce out-of-
pocket spending. Half of the HFSs (Bangladesh, Botswana,
Nigeria, and Tanzania) have objectives related to improving
efficiency. Few of the countries studied prioritized targeting
financing for the poor (only Tanzania and Senegal), and only
Vietnam’s strategy included improving quality of health care
as an objective. Other hot topics in health financing, such as
the involvement of the private sector, are only mentioned at
the objective level by Botswana’s strategy. Overall, the
Country Content Process
Diagnosis of
Performance
Entire
Population
Specific
Objectives
Evaluation
Plan
Linked to
National
Policy
Includes All
WHO Health
Financing
Technical
Areas
Inclusive
Stake-
holders
Multisectoral
Committee
Additional
Analyses
Multiround
Consultation
Bangladesh X X X X X X X
Botswana X X X X X X X X X
Cambodia X X X X X X X
Haiti X X X X X X X
Nigeria X X X X X X X X
Tanzania X X X X X X X X
Senegal X X X X X X X X
Vietnam X X X X X X X
TABLE 3. Review of Health Financing Strategies in Eight Countries
Ideal Attributes of HFS Composition
1. Informed by a diagnosis of performance relative to health system objectives
2. Applies to the entire population and the “national health system”
3. Defines specific objectives and actions for addressing identified problems
4. Contains an evaluation strategy
5. Included in or linked to national health policy or other strategic health sector document or national development plan
6. Comprehensively addresses revenue raising, pooling, purchasing, benefit design and entitlement, and governance
Good Practices for Facilitating HFS Development Processes
1. Engage key stakeholders (defined inclusively to go beyond government), especially government agencies responsible for health and finance
2. Form a multisectoral task force or steering committee with clear terms of reference, a timeline, and support from full-time dedicated staff
3. Employ best available knowledge, expertise, and data, including additional analyses beyond those immediately available
4. Prepare for a multiround consultation and revision process to achieve final approval
TABLE 2. Framework for Analyzing Eight HFSs Supported by USAID
Cali et al.: Emerging Lessons from National Health Financing Strategies 139
6. review revealed that these countries are prioritizing financial
sustainability, financial protection through pooling/insur-
ance, and improving efficiency in their health financing
strategies.
Strikingly, none of the HFSs reviewed included a specific
evaluation plan, and only four of the eight have any guidance
for monitoring the strategy. This is in contrast to the WHO’s
emphasis on the importance of learning from implementation
experience, making mid-course changes to the strategy, and
being accountable to the public.7
Senegal’s HFS was the
closest to including a monitoring strategy but still lacked
important details such as a final list of monitoring indicators.
The Senegal HFS assigns the task of monitoring and evalua-
tion to the multipartner universal health care steering com-
mittee, includes an annex of potential monitoring indicators,
and calls for a mid-course internal evaluation and an external
final evaluation. The Bangladesh strategy includes indicators
but no time frame or an explicit plan for evaluation. The
Cambodia strategy includes the provision for the creation of
a council to oversee the whole social protection strategy,
including pensions, health, and social assistance efforts.
Among the council’s functions is the evaluation of the strat-
egy every five to ten years, but this falls considerably short
of an evaluation plan. The Vietnam HFS includes a table that
has broad categories of indicators for monitoring, but it also
falls short of a specific evaluation strategy.
All of the health financing strategies are documents
explicitly linked to broader sector or national strategies and
are not stand-alone efforts, although none of the eight HFSs
meets the ideal of being embedded within a national health
policy, other strategic health sector document, or national
development plan. For example, the Cambodia health financ-
ing strategy is part of an overall national social protection
strategy, and the development of health financing strategies
in Haiti, Botswana, and Tanzania was called for in the
countries’ health sector strategies. Botswana’s HFS cites its
long-term development plan “Vision 2036: Achieving Pros-
perity for All”10
and Senegal’s HFS cites its “Emergent Sen-
egal”11
vision. Vietnam’s strategy is considered a document
of the country’s 12th Party Congress on socioeconomic
orientation.
Ideally, all HFSs should address the WHO framework’s
five aspects of health financing: revenue raising, pooling,
purchasing, benefit design and entitlement, and governance.7
Though all eight HFSs include revenue raising, pooling, and
purchasing explicitly or implicitly, only two of the strategies
address all five areas recommended by WHO. Senegal’s and
Botswana’s HFSs explicitly address benefits design, calling
for the development or revision of a basic package of serv-
ices to be covered for all. Both strategies also address
governance: Senegal’s strategy specifies a multipartner uni-
versal health care steering group chaired by the prime minis-
ter and supported by a secretariat at the ministry of health,
and Botswana’s calls for improved public financial manage-
ment. Cambodia’s strategy does not address benefits design
but does address governance, calling for a multiministerial
national social protection council. The other HFSs do not
address governance or benefit design/entitlement and thus
are potentially leaving important aspects of health financing
out of their strategies.
The composition of the HFSs includes several ideal attrib-
utes such as a situation analysis, addressing the whole popu-
lation, having specified objectives, and being linked to other
national policies. They deviate, however, from the ideal in
terms of including explicit evaluation strategies and address-
ing benefits packages and governance mechanisms, though
each of these items is partially addressed by one or more of
the HFSs. The recurring themes that appear in the objectives
of the HFSs provide a glimpse of the health financing priori-
ties in low- and middle-income countries. These include sus-
tainability in the context of stagnating donor spending,
financial protection through risk pooling, and efficient use of
resources.
Health Financing Strategy Development Process
All of the HFSs examined showed the importance of involving
a multitude of stakeholders, including those from outside the
health sector, in the HFS development process. As expected,
the government agencies responsible for health (usually minis-
try of health) led the development of most HFSs, with the
exception of Cambodia. In that country, the Ministry of Econ-
omy and Finance led the development of the social protection
strategy of which the HFS was a component. Surprisingly,
some countries did not include the government agencies
responsible for finance in the development of their strategies.
Despite being the agency responsible for allocating budgets to
the rest of the government, ministries of finance were only
included in five of the eight HFSs. International assistance
partners were involved in the HFS development process in all
countries, albeit with different roles in each country. The pri-
vate sector actively participated in the HFS processes in only
three countries: Botswana, Tanzania, and Senegal.
All of the HFS processes examined were guided by a mul-
tisectoral steering committee or technical working group,
with the exception of Haiti. The processes resulted in a draft
strategy after nine months to two years of work, regardless of
timelines established by the countries. The Senegal HFS
development effort had an aggressive timeline of six months
and used a USAID-financed Senegalese staff, but the country
140 Health Systems & Reform, Vol. 4 (2018), No. 2
7. was able to complete a draft strategy after nine months of
work and achieve formal approval in a little more than a
year. Cambodia did not have a specific timeline but arrived
at an approved social protection strategy in about two years
using Ministry of Economy and Finance staff as a secretariat.
In Bangladesh, the HFS was designed and approved in a year
from the launch workshop and was supported by the Ministry
of Health’s Health Economics Unit and donor-financed con-
sultants. In Haiti, the process has taken over three years and
has yet to be completed. Delays have been the result of
changes in government and lack of political will. Botswana’s
strategy was started in 2012 but work stalled for nearly three
years due to loss of donor technical support. After HFG assis-
tance began in 2015, a draft was developed by donor-funded
consultants and the Ministry of Health and Wellness’s health
economics staff and submitted to the minister of health one
year after the first stakeholder meetings.
Half of the countries found it necessary to conduct addi-
tional analysis to inform the development of their HFS. Tan-
zania commissioned working papers in multiple thematic
areas, although the papers took approximately one year to
complete. Haiti and Botswana supplemented their situational
analyses with stakeholder discussions and interviews, and
HFG assisted Botswana to conduct a financial gap analysis
and produce reports on options for improving health sector
efficiency and potential national health insurance design.12–
14
HFG supported Nigeria with a political economy analysis
to inform the strategy. Although Senegal, Cambodia, and
Vietnam did not conduct additional analyses to inform strat-
egy development, they did make use of existing international
experience to assist their HFS processes. Senegal made bibli-
ographies of global experiences available to its thematic
working groups, and Cambodia and Vietnam extracted les-
sons from international experience with implementation of
aspects of their strategies. In Haiti, requests for new analysis
have stalled the strategy development process, and some
stakeholders have expressed that additional analysis is not
necessary.
All eight countries used a multiround consultation and
revision process to move toward final approval, and the
approval process has been slow moving and complex in
most countries. For example, Senegal’s HFS went through
ten drafts between March and July 2017 before initiating
the formal ministry of health approval process. It still
needs to be approved before it can be implemented. Bot-
swana submitted its strategy to the minister of health in
October 2016. At the time of writing, the health financing
technical working group is still responding to the minis-
ter’s questions and concerns.
DISCUSSION
Systematically reviewing and reflecting upon these eight
countries’ experiences with developing HFSs has revealed
several lessons and challenges that may be useful for other
countries wishing to develop or update existing HFSs. Here
we explore five themes that emerged from this analysis.
Use of Data
This review of health financing strategies highlights two les-
sons related to the production and use of data. First, HFS
development processes have nurtured an appetite for health
financing data among policy makers in low- and middle-
income countries. Most HFS processes reviewed in this arti-
cle generated opportunities for policy makers to review and
discuss national health accounts data, fiscal space analyses,
and household survey results when analyzing their health
financing situations. These discussions allowed policy mak-
ers in ministries of health and other institutions to see the
usefulness of interpreting multiyear trends in health financing
data and analyzing sub-national and cross-country data and
revealed when health financing data were out-of-date or
missing. The authors’ experiences suggest that observing the
importance of health financing evidence during the course of
an HFS process can solidify commitment among policy mak-
ers to generate accurate, timely health financing data.
Second, this review of HFS development processes
revealed the need to advance strategy development regard-
less of the quality of data available. The countries examined
in this article largely accepted that developing a strategy
using the best data available was better than having no strat-
egy, despite the fact that some health financing data were
missing or out of date. For example, Botswana advanced
with its HFS development using NHA projections from
2010 while collecting 2013–2014 NHA data in parallel.15
Several countries were able to commission and complete
additional studies relatively quickly to inform HFS develop-
ment but limited these exercises to those that could be com-
pleted within a year. The additional studies included
financial gap analyses, political economy analyses, and pol-
icy options or thematic working papers. In contrast, Haiti’s
Ministry of Health and other stakeholders have delayed
HFS development with various requests for additional infor-
mation, such as a costing of the essential health package
and estimations of the amount of resources that could be
raised through innovative financing. Though important and
useful, this information is not critical to the development of
an HFS.
Cali et al.: Emerging Lessons from National Health Financing Strategies 141
8. Cross-Country Learning
The experiences of countries reviewed in this article demon-
strate that cross-country learning is valuable for developing
an HFS, despite the uniqueness of each country’s context.
With the support of development partners, countries
employed several creative mechanisms for benefiting from
international experience in the development of their HFSs.
For example, Cambodian officials participated in study tours
to Indonesia, Thailand, South Korea, and Japan to gather
ideas for designing their health financing arrangements. In
Botswana, officials closely reviewed and discussed health
insurance designs in Ghana and Thailand to explore whether
and how they might be relevant for the country. They also
learned from South Africa’s experience and invited private
medical aid schemes to be heavily involved in the HFS pro-
cess to avoid the resistance to reform demonstrated by simi-
lar entities in South Africa. Vietnam asked for an analysis of
how other countries had sequenced the implementation of
components of their HFSs. Senegal expedited its HFS devel-
opment process by relying on bibliographies of technical
content and guidance gathered from other countries and
international organizations rather than commissioning its
own studies. Senegal’s steering committee saved time defin-
ing its HFS vision by borrowing ideas from the policies of
other countries that resonated most with the local context.
Fostering cross-country learning and exchange of ideas is
one of the principle roles of development partners for support-
ing HFS processes. Development partners can promote the dif-
fusion of health financing innovations and good practices by
serving as neutral facilitators of knowledge exchange among
low- and middle-income countries. HFG found that connect-
ing government officials in countries developing HFSs with
information and people from low- and middle-income coun-
tries that had recently undergone health financing reform and
interpreting the context of these reforms were seen as valuable
contributions to the HFS development processes.
Evaluation and Improvement
The 2010 World Health Report envisioned designing and
implementing a health financing strategy to be a cyclical pro-
cess of constant reevaluation and adaptation of existing
policies.6
The WHO’s guidance for HFSs suggested that all
countries include an evaluation strategy.7
In practice, none of
the eight HFSs reviewed here included a well-developed
evaluation strategy with defined indicators, timelines for
review, and clear responsibility assigned to an institution for
monitoring and evaluation. The countries instead structured
the development of an HFS as a one-off or ad hoc task, albeit
to varying degrees, with no clearly defined plan or legal man-
date for revising the strategies or repeating the strategy
development processes.
There are several reasons why the countries reviewed in
this article may not have included defined monitoring and
evaluation plans for their HFS. First, the multisectoral com-
mittees and technical working groups established to develop
the HFS were inclusive of many interests and stakeholders
but in most countries were not institutionalized and resourced
to engage in ongoing assessments and revisions of the strate-
gies. (Senegal and Cambodia were exceptions that at least
assigned responsibilities for monitoring the strategy.) Some
countries have too few staff and lack the capacity in the pol-
icy or health financing departments of their ministries of
health to produce health financing data or even qualitatively
evaluate their HFSs without significant support from devel-
opment partners. Second, it is possible that countries will
monitor and evaluate their HFSs but have not found it neces-
sary to include an evaluation plan as a section of the HFS.
The WHO’s health financing guide states that an HFS should
“live somewhere between high level documents which out-
line a vision for the health sector, and implementation docu-
ments which provide detailed plans.”7
The countries
reviewed here may decide to develop evaluation plans that
are linked directly to implementation documents developed
after receiving formal approval of the strategies, rather than
to the broader HFS. Finally, countries may prefer to integrate
monitoring and evaluation of the HFS into a comprehensive
monitoring and evaluation framework for the health sector to
avoid the proliferation of multiple plans. Overall, the coun-
tries reviewed in this document do not have the resources or
capacity to monitor and evaluate their HFSs or will use
another mechanism, separate from the HFS itself, to monitor
and continuously improve the HFS.
Leadership Involvement
HFSs have the potential to impact all areas of a national health
sector and large segments of the economy and can produce visi-
ble changes in the lives of people and bottom lines of compa-
nies. HFSs are inherently political and the stakeholders
developing the HFS, especially ministers of health and minis-
ters of finance, cannot avoid engaging with politicians, parlia-
ments, and interest groups during the HFS development,
approval, or implementation processes. Hence, countries need
to consider how closely cabinet-level ministers should be
involved in the development of the HFS. Involving ministers or
their top advisors closely in the process from the beginning pro-
vides several advantages. Ministers of health and finance can
provide guidance on the types of reforms that will or will not be
142 Health Systems & Reform, Vol. 4 (2018), No. 2
9. palatable for the political leadership, thus steering the strategy
toward politically viable and financially feasible solutions and
away from reforms that may in theory achieve the health sys-
tem’s objectives but never be implemented due to political
opposition. Furthermore, close minister-level involvement will
prepare ministers of health and finance to advocate for the
reforms defined in the strategy in front of legislatures, execu-
tives, and the general public. For example, the active leadership
of the Cambodian Secretary of State of the Ministry of Econ-
omy and Finance as the chair of the Social Protection Working
Group may have helped the social protection strategy, which
included health financing, to win swift approval. On the other
hand, close involvement of minister-level leaders presents sev-
eral risks. Ministers of health and their top advisors have many
responsibilities and busy agendas. Structuring an HFS process
around a minister’s availability could delay the process and pre-
vent the steering committee or working group from meeting
regularly. As political appointees, ministers of health and
finance can be replaced with frequency. Tying the HFS devel-
opment process too closely to the minister of health risks jeop-
ardizing the process if the minister is replaced. This occurred in
Haiti, delaying the HFS development process.
Progressing with the HFS process without close involve-
ment of high-level ministers has its own advantages and
risks. Excluding high-level politicians from initial technical
discussions could allow technical staff to work on solutions
that would be dismissed quickly by politicians due to fear of
political resistance. It could also give space for technical
experts representing different stakeholders to brainstorm
compromise solutions among competing organizations or
industries. Politicians may be less willing to engage in such
discussions. Moreover, not being involved in technical dis-
cussions could allow ministers of health to portray the work-
ing group or committee as an independent body of experts
not influenced by politics. The HFS could then be used to
advocate for changes to the political environment to accom-
modate technically superior health financing arrangements,
rather than allowing the political environment to dictate or
limit specific technical reforms to those with superficial polit-
ical appeal. On the other hand, not involving high-level min-
isters in the HFS development process makes it more
difficult for the minister to understand the details of proposed
reforms and how and why the group decided to pursue cer-
tain paths. In Botswana, technical staff from across the gov-
ernment, private, and nonprofit sectors designed the HFS
with limited input from the minister of health. When pre-
sented with a draft, the minister responded with many ques-
tions about the findings of the situational analysis, the
decision-making process for developing the HFS, and the
implications of the suggested reforms. At the time of writing,
the health financing technical working group has been work-
ing for nearly nine months to address the minister’s concerns
and win approval of the strategy.
Stakeholder Management
Management of stakeholders is an important aspect for coun-
tries to consider when developing an HFS. Ministries of health
will typically need to decide who to invite to participate in the
HFS development process and how to assign tasks to specific
stakeholders. The WHO recommends the involvement of an
inclusive group of government agencies including health,
finance, local government, social security, and education, in
addition to legislative bodies and nongovernmental partners.7
The WHO also suggests including in the development of the
strategy those organizations responsible for its implementation.7
The eight countries reviewed in this article invited a host of
government agencies, including ministries of defense and jus-
tice in Cambodia, regional and local governments in Tanzania
and Senegal, and the Competition Authority (antitrust agency)
in Botswana. Foreign assistance agencies, private insurers, and
nongovernmental agencies were also invited. Service provider
representatives did not participate in the process in any of the
countries, despite the potential impact of an HFS on their work.
The countries reviewed in this article sought to build inclusive
coalitions for HFS development in order to foster a broad sense
of ownership for the strategy and prevent resistance from stake-
holder groups to the strategy’s approval. It is not clear how
including certain stakeholders in the process may have influ-
enced the technical content of the strategy and thus the strat-
egy’s likelihood of contributing to health system objectives. For
example, HFS development processes with large participation
of the private insurance sector may be skewed in favor of pri-
vate insurance options at the expense of health sector efficiency.
The second aspect of stakeholder management involves
how to organize stakeholders and delegate specific tasks
required for HFS development. Senegal divided stakeholders
into thematic working groups focusing on revenue collection,
pooling, purchasing, governance, monitoring and evaluation,
and social determinants. In Botswana, private insurers were
asked to present on health insurance operations. In Cambo-
dia, development assistance partners were only invited to
comment on drafts of the document. Despite their differen-
ces, all of these approaches resulted in HFS documents that
were aligned with health sector objectives.
CONCLUSION
In the years since the release of the 2010 World Health
Report and subsequent guidance from the WHO,6,7
the global
Cali et al.: Emerging Lessons from National Health Financing Strategies 143
10. health community has reached a consensus that low- and
middle-income countries can benefit from developing HFSs
roughly aligned with the framework discussed here. Based
on work supporting eight countries, this article highlights
valuable lessons and considerations for future HFS develop-
ment efforts, including guidance on useful data for situa-
tional analyses, ways to take advantage of cross-country
knowledge exchange, ideas for how and when to involve cab-
inet ministers, and examples of how to manage broad stake-
holder groups. It also provides critical information, based on
real-world experiences, to guide international organizations
supporting HFS development in low- and middle-income
countries. For example, this analysis found that countries
often are not including monitoring and evaluation plans
within their HFSs and provides guidance on how develop-
ment partners can encourage and facilitate cross-country
learning for HFS development.
As more countries produce or update their HFSs, develop-
ment partners and governments should continue identifying
good practices for the development process and, most impor-
tant, the implementation of the strategies. Governments would
benefit from more guidance for navigating the political aspects
of the development process, such as which stakeholders to
include and how to reconcile conflicting political preferences.
Countries wishing to develop HFSs would also benefit from a
comparison of different approaches to developing HFSs and
their impact on implementation of the strategies. Finally, more
extensive documentation of local policy makers’ experiences
and feedback on HFS development processes, including their
opinions on the best structure, utility, and outcomes of such
processes, would provide an essential perspective on HFS
development processes not captured here.
The ultimate impacts of the eight HFSs reviewed here may
not be visible for years, but past experience suggests that
HFSs can be a catalyst for major health system reforms.16
The
lessons and challenges highlighted in this article can help low-
and middle-income countries to develop HFSs that are techni-
cally strong, politically viable, and potentially critical steps
toward advancing universal health coverage.
DISCLOSURE OF POTENTIAL CONFLICTS OF
INTEREST
The authors report no conflict of interest.
ACKNOWLEDGMENTS
The authors acknowledge the dedication and collaboration of
local officials and policy makers in Bangladesh, Botswana,
Cambodia, Haiti, Nigeria, Tanzania, Senegal, and Vietnam
working to develop and implement health financing strate-
gies in their countries. We also acknowledge the contribu-
tions of Sylvester Akande, Gafar Alawade, Elaine Baruwa,
and Ekpenyong Ekanem of HFG Nigeria for sharing their
experiences working with Nigeria’s health financing strategy
and Abdo Yazbeck for his insightful comments and
guidance.
FUNDING
This manuscript was funded by the U.S. Agency for Interna-
tional Development (USAID) as part of the Health Finance
and Governance project (2012-2018), a global project work-
ing to address some of the greatest challenges facing health
systems today. The project is led by Abt Associates in collab-
oration with Avenir Health, Broad Branch Associates, Devel-
opment Alternatives Inc., the Johns Hopkins Bloomberg
School of Public Health, Results for Development Institute,
RTI International, and Training Resources Group, Inc. This
material is based upon work supported by the United States
Agency for International Development under cooperative
agreement AID-OAA-A-12-00080. Some of the work docu-
mented in this report was financed by the Health System
Strengthening Plus Component (HSSC) of the USAID/
Senegal Health Program, 2016-2021. The Health System
Strengthening Plus program component consists of technical
assistance to the Government of Senegal implemented by
Abt Associates, Inc., in partnership with Association Conseil
pour l’Action, Africa Resources Group, Groupe Issa, PLAN,
Results For Development, and World Vision.
The contents are the responsibility of the authors and do
not necessarily reflect the views of USAID or the United
States Government.
ORCID
Yann Derriennic http://orcid.org/0000-0002-9546-1517
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