Presentation made by Barbara McPake at the international stakeholder meeting - 'Health after conflict - Rebuilding the system' held on 13th December 2016 at the Wellcome Trust in London.

1. Barbara McPake
Health after conflict – Rebuilding the system
13th December 2016
Wellcome Trust, London

2. • A focus on the interaction between health systems,
financing policies, poverty and conflict
• 2 components:
• Reanalysis of household survey data aiming to identify
impact of health financing policy changes on
households’ access to health care and expenditure
patterns pre-conflict, during conflict and post-conflict
(as permitted by data).
• Life history study of older heads of poor households
and their health care use before, during and after
conflict, focusing on relationships between health
seeking behaviour, expenditures on health care,
conflict and health and poverty experiences.
Background on health financing research

3. Background on health financing research

4. Results from survey reanalysis: Sierra Leone
• Free Health Care Initiative (FHCI) introduced in
2010 had relatively small effects.
• The proportion of children who accessed care
with payment increased, but not children’s
utilisation of care overall, and use of informal
sources of care may have decreased.
• Use of maternal health services increased
substantially but was not sustained over time
– most likely due to supply side constraints.

5. Results from survey analysis: Cambodia
• Complex mix of financing policies
• the formalisation of user fees in public health facilities
• the introduction of health equity funds (HEFs), both
government and donor funded, which fund the exemption
of poor households from fees
• vouchers for pregnant women to cover costs of maternal
care in public health facilities
• community based health insurance
• contracting arrangements by which public subsidies are
allocated by a contract rather than budgetary process.
• First attempt to consider them across all their combinations
• Overall, rollout of schemes associated with general reduction in
OOP by poor
• Equity funds associated with reduced OOP; vouchers more
modest effect but stronger when combined with other
schemes.
• Effects increase over time

6. Results from survey analysis: Uganda
• Withdrawal of user fess from all public health
facilities occurred in 2001
• Over 90% of population of Northern Uganda in
internal displacement camps at that time – not
directly affected
• We studied impact of population’s return from
camps after 2006 on household budget and
health expenditure patterns
• Food consumption increased. Overall utilisation
of health services did not change significantly but
shift from formal private services to informal
private services and public services, especially for
poorest

8. Life history findings: country specific issues
• Zimbabwe: post-crisis period after ‘dollarization’
reduced households’ capacities to cover costs – fees
in hard currency; inadequately funded social
protection; under-funded public services push people
to private sector
• Uganda: poorly functioning public system with
frequent drug stock-outs and physical access
challenges means frequent use of drug shops and
small private clinics if resources available
• Sierra Leone – wide regional variation in cost
experience - catastrophic outcomes from both non-
use and expensive but ineffective use of health care
• Cambodia: schemes to support poor households
access affordable health care help, but fail in the end
to protect households from poverty becauase of
chronicity of problems and less than full subsidy

9. Conclusions/Recommendations 1
• Life histories explain and contextualise household survey
analysis; Both sets of findings largely consistent
• Health financing policies targeted at removing or reducing out
of pocket health expenditure are essential interventions in
processes that drive and maintain poverty at household level,
many of which originate or were exacerbated by conflict.
• Health financing policies limited effectiveness in addressing
processes of poverty because:
• not fully implemented – e.g. formal fees replaced by informal
ones.
• inadequate funding to support effective service delivery: health
utilisation and expenditure redirected to private and informal
health providers
• insufficient coverage of ancillary costs
• incentives for the health workforce to ensure access to effective
services and non-discriminatory treatment of exempted
populations are inadequate
• unfunded exemptions result in an impossible choice for service
providers between honouring exemptions and maintaining
service provision.

10. Conclusions/Recommendations 2
• Problems result from piecemeal rather than systemic
understanding of intervention. In conflict affected settings,
capacity and staff experience limitations are particularly
important
• Longer term consideration of impact needed: not discrete
before/after effect but one that evolves. Attention needs to be
paid to how to reinforce policy intentions in the processes of
health system management and support over the long term.