MSH Presents on the Role of Financing in Improving Access to Health Care

MSH Presents on the Role of Financing in Improving Access to Health Care at the 3rd Global Symposium on Health Systems Research in Cape Town, South Africa

On September 30 – October 3, 2014, nearly 3,000 researchers, program managers, and policy makers convened in Cape Town, South Africa for the 3rd Health Systems Research Symposium to review evidence and research focused on improving people-centered health systems and service delivery. A key component to strengthening health systems and improving health outcomes is through health care financing mechanisms. To explore this issue, three MSH staff members participated in a panel entitled the Role of Financing in improving access to health care: Experiences from Indonesia, Myanmar, Rwanda and other countries. Moderated by Michael Myers (Managing Director at the Rockefeller Foundation), the panel featured presentations from David Collins (MSH Senior Principal Technical Advisor – Health Care Financing), Uzaib Saya (MSH Senior Technical Officer -Health Care Financing), Dr. San San Aye (Director of the Department of Planning at the Ministry of Health, Republic of the Union of Myanmar), and Colin Gilmartin (MSH Technical Officer – Health Care Financing).

Presenting on the economic burden of tuberculosis in Indonesia, David Collins demonstrated how 25-year TB case projections can be used to advocate for long-term financing and investment into the health system. Despite increased external financing for TB case detection and treatment in Indonesia, there remains a significant gap in TB services for which the cost of inaction is high. Collins cited the high productivity loss and out-of-pocket spending associated with undetected cases and explained that TB treatment and prevention go hand-in-hand. “The more TB cases that can be treated, the more cases we can prevent.” According to Collins, assuming a TB case treatment rate of ~ 70%, a per capita $0.33 investment in medical costs for TB case detection and treatment can result in per capita $9 of savings to the health system and society as a result of improved productivity.

David Collins, MSH Senior Principal Technical Advisor - Health Care Financing, describes the projected financing required to effectively limit the gap in TB services in Indonesia.

David Collins, MSH Senior Principal Technical Advisor – Health Care Financing, describes the projected financing required to effectively limit the gap in TB services in Indonesia.

Presenting on the Government of Rwanda’s community-based health insurance (CBHI) social protection scheme, MSH’s Uzaib Saya cited preliminary research conducted in partnership with the Ministry of Health and the University of Rwanda’s School of Public Health. Findings showed that CBHI has afforded individuals lowered costs of health services and better access to medications. According to Saya, Rwanda’s CBHI scheme, which in 2013 initiated a sliding scale premium structure based on household-level income categories, increased financial protection to the poorest groups. Data from 1,300 households indicate that financial catastrophe was only observed in 0.38 percent of households and impoverishment rates as a result of out-of-pocket health payments have reduced considerably. Nevertheless, according to Saya, “these findings demonstrate that more efforts need to be undertaken to reduce the burden of inequalities related to out-of-pocket payments and CBHI premiums especially for poorer households.”

Uzaib Saya, MSH Senior Technical Officer – Health Care Financing, presents on the impact of Rwanda’s Community-Based Health Insurance (CBHI) Scheme.

Uzaib Saya, MSH Senior Technical Officer – Health Care Financing, presents on the impact of Rwanda’s Community-Based Health Insurance (CBHI) Scheme.

Recognizing the unique health challenges of Myanmar’s 330 townships, Dr. San San Aye presented on the importance of health planning at the township levels and financing in population health, and in achieving a pathway toward universal health coverage. According to Dr. San San Aye, while tax-based financing has increased government health expenditure in recent years, out-of-pocket payments must be reduced and social assistance programs must be increased at the township levels to ensure financial protection of Myanmar’s people.

San San Aye, Director of Planning at the Ministry of Health, Republic of the Union of Myanmar, presents on the unique challenges of Myanmar’s townships and financial investments required to achieve universal health coverage.

San San Aye, Director of Planning at the Ministry of Health, Republic of the Union of Myanmar, presents on the unique challenges of Myanmar’s townships and financial investments required to achieve universal health coverage.

Colin Gilmartin presented on the costs and cost-effectiveness of integrated community case management (iCCM) programs in seven countries in Sub-Saharan Africa. While iCCM programs are often considered to be a relatively cheap and low-cost intervention for treating childhood illnesses in hard-to-reach areas, results of MSH-led costing analyses  indicate that high program costs and low utilization can reduce the cost-effectiveness of such programs. According to Gilmartin, a comprehensive understanding of the costs and financing involved in iCCM programs allows countries, program managers, and policy makers to examine key cost-drivers (e.g. management, supervision, supply chain, and program overhead costs) and to advocate and plan for the efficient use of scarce resources. According to Gilmartin, “CHW programs and services must be well-utilized in order to be cost-effective.”

Colin Gilmartin, MSH Technical Officer - Health Care Financing, displays the pictures of three CHWs from Senegal, Cameroon, and Sierra Leone to illustrate the similarities of their job function but also how differences in their environments can affect the cost of community-based health services.

Colin Gilmartin, MSH Technical Officer – Health Care Financing, displays the pictures of three CHWs from Senegal, Cameroon, and Sierra Leone to illustrate the similarities of their job function but also how differences in their environments can affect the cost of community-based health services.

The four presentations highlighted experiences across countries and the impact of health financing strategies on improving access to health care.

Learn more about MSH’s role at the Health Systems Research Symposium and about MSH’s other activities related to Health Care Financing.


Health Systems Research Shapes Governance Impact

This post also appears on the LMG for Health blog.

There is a growing pool of studies that good governance matters as “The Big Enabler” for health systems strengthening.

Health systems researchers in the Capetown, South Africa, Third Global Symposium on Health Systems Research explore the theory of change that guides governance interventions: a solid governance infrastructure enables sound management of health systems, which increases the probability that health services will be better used and health outcomes will improve.

Both policy makers and health service providers have become interested in how good governance increases the probability that health services will be better used for better health outcomes.

But why do they believe that?
How is it possible that better governance can yield better health?
I think the short answer is… it cannot UNLESS certain conditions are available. Conditions like:
  • structures for governance decision-making (governing bodies of various types and sizes) that have clear terms of references and effective leadership;
  • participants in the governing processes that understand their roles and responsibilities;
  • decision-making processes that understand and effectively accomplish the 4+1 practices of:
    • create a culture of accountability;
    • engage diverse stakeholders;
    • set strategic directions;
    • steward scarce resources; and then
    • continuously improve the above practices.
  • leadership staffing that supports and enhances the work of the governing bodies;
  • enough resources that allow governing decisions to actually get implemented; and
  • a context and culture that has rule of law and ethics that demand results and transparent decision-making.
Where is the evidence that smart governance matters?
These substantial studies show the power and value of good governance to enable the work of those who deliver, manage and lead health services organizations:

Celebrating African Health Leaders at the Global Symposium on Health Systems Research

Wednesday evening was spent celebrating the work and vision of African Leaders driving for stronger health systems and greater health outcomes in Sub-Saharan Africa. After a day of thought provoking sessions at the Global Symposium on Health Systems Research, Lord Nigel Crisp, Former Chief Executive of the UK’s National Health Service (NHS)  and Dr. Francis Omaswa, Executive Director of the African Centre for Global Health and Social Transformation (ACHEST), launched their new book, African Health Leaders: Making Change and Claiming the Future.

The book, with support from The Rockefeller Foundation, KPMG, and Oxford Press, is a collection of this of important stories and lives from 23 Sub-Saharan African health leaders and provides an inspiring vision for the future: African health leaders claiming their own future for their people and health systems; forging new relationships with international donors and partners to invest in growing deep roots into the soils, society and economies of traditionally low resourced countries.

In the past, as Omaswa asserts in Chapter 2, to improve their health systems, Africans went to institutions and countries for advice and money and got both.  But often this was in exchange for certain core values that in too many instances did not reinforce or acknowledge the traditional insights needed for the ownership and pride to sustain the solutions.

Her Excellency Dr. Nkosazana Dlamini-Zuma, Chairperson of the African Union Commission based in Ethiopia says it well in her dedication to the book: “As Africans we must celebrate improvements in health and the people who have made them happen, but we must also claim our own future for ourselves. Written by Africans, this book is essential reading for African health leaders who want to build on our own traditions and experience. It is also a vital orientation for partners who want to know how they can best support our efforts in a spirit of global solidarity.”

Three of the authors were present at the book launch to share their stories: Dr. Hannah Faal; Dr. Peter Eriki; and Dr. Ndwapi R. Ndwapi.

Dr. Hannah Faal was born in Nigeria and received a Fellowship to the Royal College of Surgeons in Edinburgh in 1975. She is respected for her pioneering work in The Gambia where she established the national eye care program that lead to The Right to Sight, a global initiative of WHO and the International Agency for the Prevention of Blindness, of which she became the President.

Dr. Peter Eriki attended the LMG Global Roundtable on Governance for Health in 2013 and is Director of Health Systems for ACHEST, a partner of ours supported by USAID to develop a “Ministerial Orientation Programme” that supports the capacity transfer for stronger health systems in Africa. Eriki has served as the WHO country representative for over 15 years in several priority African countries. He played a significant role in the revitalization of immunization programmes in Nigeria which had threatened to derail the global polio eradication effort. For this he received the Paul Harris Fellowship by Rotary International. He has his medical degree from Makarere University in Uganda and an MPH from Harvard.

Dr. Ndwapi R. Ndwapi is currently Manager of the Ministerial Strategy Office of the Ministry of Health in Botswana. Heralded as one of the “young leaders for health in Africa,” he has had responsibility as Director of Clinical Services with overseeing Botswana’s 26 public hospitals and more than 500 free-standing public outpatient clinics.

We can all learn from this collection of innovators and leaders about the knowledge, skills and attitudes it takes to address and master the many health challenges in Sub Saharan Africa. The launch was an inspiring evening with real change-makers from health systems in Africa.

Photo Credit: ACHEST. From Left: Lord Nigel Crisp, Prof. Francis Omaswa, Hon. Ruhakana Rugunda, Susan Edjang, Prof. Miriam Were, and Hon. Okello Oryem

Patient-Centered and Integrated Services (PCIS): Is it Primary Health Care (PHC) by another name?

This morning, October 1, 2014, a panel that was moderated by Edward Kelley, Director for Service Delivery and Safety at the WHO, introduced and explored the rationale and strategic directions outlined in a new WHO strategy on People-Centered and Integrated Health Services. The strategy outlines four core priorities for health systems: empowering users and population groups; strengthening engagement and accountability; coordinating services and setting and implementing system priorities. The principles that underpin the strategies include: country led and owned process; equity focused; people’s voices are heard; recognition of interdependence of different levels of health system; learning and action cycles.

A provocatively interesting question from the audience was: what is the difference between PCIS and PHC? And what have we learned from the failures of PHC to make the new PCIS strategy successful. Part of the solution lies in the ability of the research and policy community to use evidence to articulate a compelling case on the need for change – basically demonstrate that the current models of care are fragmented and are excluding many people and creating a culture of “us” and “them”. It also emerged that the narrative for change should not necessarily be premised on cost-containment but bringing people to the center of the health system, with strong emphasis on responsiveness and people’s perspectives. Once a coalition of support has been established, the next step is to invest in implementation know-how and the governance infrastructure that is required to make it happen, and to understand what works by doing.

Strengthening Health Systems Journal Publishes MSH Editorial

Sometimes the people who know best are, well, the people. Achieving the fundamental objectives of UHC and meeting the challenges of governing complex health systems requires people-centered schemes that include formal mechanisms to bring civil society and communities into the design and implementation of UHC programmes.

In its second issue, The Strengthening Health Systems journal has published an MSH editorial titled, “People-centered health systems for UHC: How to put people first while increasing health service access.” Written by MSH CEO Jonathan Quick, Senior Writer Jonathan Jay, and Research & Communications Specialist Chelsey Canavan, this editorial discusses a people-centered approach to UHC, highlighting three areas where civil society and communities play vital roles: ensuring the right services are provided under an essential package of health services, removing barriers to care such as user fees, and ensuring equitable access to health services.

In each of these areas and at every level of the health system, citizen representation is essential. Bringing communities into the process at every step in the design and implementation of UHC will help ensure meaningful increases in equity and improvements in health outcomes for the people the health system is meant to serve.

A PDF download is available and more information about the latest issue is available on the Strengthening Health Systems website.


The Health System Belongs to the Whole Community

Photo Credit: Mark Tuschman

Photo Credit: Mark Tuschman, 2014

At the Third Global Symposium on Health Systems Research, the theme of improving health outcomes permeates discussions around data, prevalence, coverage rates and policy. The theme of the week is the “science and practice of people-centered health systems”. Questions have been posed, to be fleshed out over the next three days. What does “people-centered” mean to those working on the frontlines? And what are the actionable implications of the widely agreed upon right to health?

The Chair of Health Systems Global, Irene Agyepong, compared the health system to a Nigerian proverb: “the goat that belongs to the whole community belongs to nobody.” Without ownership, the goat will not survive. The health system also belongs to the whole community. Measurable progress in specific areas such as maternal mortality or HIV treatment rates is attributable to the health system. Without investments in proven health systems interventions, systems innovations and research, we would not witness positive impacts on health outcomes. Without fundamental public health structures, WHO Director General Margaret Chan noted, no society is stable. We must all nurture the goat that helps sustain our community.

International attention has turned to Ebola in West Africa, highlighting the health systems implications of the outbreak. At the same time, we know there is much to be done to achieve the goal of an AIDS-free generation, and to eliminate preventable maternal and child deaths. Noncommunicable diseases continue to challenge our health systems, while universal health coverage holds promise for their relief.

Throughout these conversations in Cape Town, we will continue to come back to the idea of people-centeredness: a focus on key populations, on the poor, the vulnerable. The need for increased accountability and transparency, strong governance and leadership, and the inclusion of civil society and communities will guide this dialogue. What we hope to take away is an even greater sense of urgency and collaboration, building momentum to keep building stronger health systems for greater health impact.

This post was written by Chelsey Canavan, Research & Communications Specialist and Ian Lathrop, Strategic Communications Specialist at MSH.

Governance and Health in Africa: Voices from the Opening Plenary

The Third Global Symposium on Health Systems Research is being held this week in Cape Town, South Africa with the theme “Science and Practice of People-Centered Health Centers.” The conference is holding over 100 plenary sessions, film conversations, posters, book launches, and interactive panels. It kicked off this evening with the opening plenary, Governance and Health in Africa: Pan-African perspectives on state stewardship for people’s health. Below is commentary from the opening panelists on how governance impacts health systems and the ability of people to claim their right to health.

Lucy Gilson, Co-chair, South Africa Local Organizing Consortium:

“Health systems are part of the fabric of the society of which we live. And health systems are always political. The reflection and debate of this symposium must be the basis for taking action on health decisions and social justice for all.”

Sisonke Msimang: South African Writer and Activist

“What does power, democracy, and rights have to do with the mundane bureaucratic business of delivering health?A state saying that it’s people has a right to health has great implications for how that state plans and budgets.”

Thandika Mkandawire, Professor of African Development, London School of Economics

“Health is an important social policy. People think of the protective role social policy plays. But we need to take into account the productive and informative role of social policy, especially  when it comes to health.”

Mahaman Tidjani Alou: Dean, Faculty of Economics and Law, Universite Abdou Moumoini, Niger

“Economic growth doesn’t necessarily bring access to medicines and health care to people equally. Inclusion is not guaranteed. There is a paradigm of unequal growt, but democracy can trigger inclusiveness in decision making which makes decisions more representative.”

Belgacem Sabri, Chair, Association for Defending the Right to Health, Tunisa

“Many can pay for private sector health care, but the vulnerable are left to a failing public system. There is an erosion of the right to health, which contributed to the uprisings that have happened in Tunisa. We hope to move towards better participation and people-centered decisions.”

Photo Blog: Day 2 of the Global Governance for Health Roundtable

From September 29th – 30th, over 50 thought leaders in global health are gathering in Cape Town, South Africa for the Third Global Governance for Health Roundtable. The Leadership, Management & Governance (LMG) Project is collaborating on the Roundtable with the Health Policy Project and the Health Finance and Governance Project.
On the second day of the Roundtable, conversations focused on donor investments in good governance and how to further support vulnerable populations and national civil society organizations in governance interventions.

Day 2 began with remarks from Dr. Tomohiko Sugishita (left) of the Japanese International Cooperation Agency on the panel, Investing in Good Governance as an Enabler for Health Systems Strengtheningwhich included Temitayo Ifafore, of the United States Agency for International Aid.

Robert Ndieka, a Monitoring and Evaluation Expert at the African Union Commission, observes discussions at the Global Governance for Health Roundtable.

Jan Sobieraj (center), Managing Director of the UK’s National Health Service Leadership Academy, acted as a rappateur for the roundtable along with Barry Kistnasamy of South Africa’s Department of Health (left).

LMG Director, Jim Rice, gives closing remarks at the Third Global Governance for Health Roundtable.

Posting and transfer practices among health-care workers: neglected but crucial in people-centered health systems

The severe shortage of human resources for health (HRH) in some low- and middle-income countries (LMIC) is primarily driven by inadequate training facilities, unattractive terms and conditions of service and the inequitable distribution of health care workers (HCW). However, the processes by which health workers are recruited, posted, and assigned transfers are important contributors to inequitable distribution and the erosion of morale and trust of HCW in the health system itself.

On September 30, during the Third Global Symposium on Health Systems Research in Cape Town, I was asked, at very short notice, to speak briefly on a panel hosted by Columbia University, Averting Maternal Death and Disability Program and Public Health Foundation of India.

The discussion that ensued was rich and insightful. It emerged that although nearly all countries have good policies regarding recruitment, posting, and transfers for health workers and health service managers, the practice often deviates significantly from policy. Depending on the context, these deviations can undermine the stated goals of the health system, including Universal Health Coverage (UHC). Poor practice occurs when existing systems are distorted and health care workers are not posted or transferred to the areas where they are most needed, when they are posted or transferred in a disrespectful or punitive way, or when they are denied opportunities for growth and self-determination.

Additionally, poor posting and transfer practice can be driven by the personal wishes of the transferee or the transferor, or stem from overall weaknesses in the human resource management system. Transferees may have a preference in where they work, and thus use social or patronage networks or bribery to get what they want. Transferors may respond to these requests, or they may generate a transfer for their own reasons, including dissatisfaction with health care worker performance.

The state of Tamil Nadu in India has managed to streamline its posting and transfer policies and practices and make them responsive to the needs of service delivery and population health goals.

Kenya, Malawi, Senegal and Namibia have also tried to implement various forms of emergency programs and special measures to create fair, transparent and fit for purpose systems to post and transfer HCW. In the long term, however, a comprehensive national level reform is required. This reform should be implemented in phases and guided by tools of political economic analysis and qualitative analysis on the governance challenges that are often co- associated with posting and transfer practices.

Ummuro Adano is the Global Technical Lead for Human Resources for Health (HRH) at MSH.

Photo Blog: Day 1 of the Global Governance for Health Roundtable

This post is cross-posted from the LMG for Health blog.

From September 29th – 30th, over 50 thought leaders in global health are gathering in Cape Town, South Africa for the Third Global Governance for Health Roundtable. The Leadership, Management & Governance (LMG) Project is collaborating on the Roundtable with the Health Policy Project and the Health Finance and Governance Project.

On the first day of the Roundtable, topics covered ranged from measuring the value of governance, including vulnerable populations in governance, and case studies on decentralization in Kenya and Afghanistan.

Ayanda Ntsaluba (right) Executive Director of Discovery Health and Former Director-General of Health for South Africa, welcomes participants to the Third Global Governance for Health Roundtable.

Participnat Eunice Seekoe. Head of the School of Health Sciences at the University of Fort Hare, South Africa.


Chantal Uwimana, Regional Director for Africa and the Middle East for Transparency International, moderates the session, “Transparency, Accountability, and Trust: Bridges to more Equitable Access to Services,” which included panelist Jeremy Kanthor (left) Governance Advisor for the Health Finance and Governance Project.

Participants engage in a lively discussion including Barry Kistnasamy the Compensation Commissioner for South Africa’s Department of Health (center).


Tshepo Kgositau, Regional Coordinator for Gender DynamiX, delivers comments for the session, “Inclusion: Engaging Vulnerable and Marginalized Populations in Governance for Health Gains.”


Panelist for “Politics and Health Governance: Strategies for Ensuring Commitment to Health Systems.” From left:  Derick Brinkerhoff, Distinguished Fellow in International Public Management, RTI International, Health Policy Project (HPP);  Anele Yawa, Representative, Treatment Action Campaign;  Aaron Mulaki, Health Systems/Public Administration Advisor, HPP/Kenya, RTI International; Christopher Tapscott, Director, School of Government, University of the Western Cape; and Robert Ndieka, Monitoring and Evaluation Expert, African Union Commission.