Building institutions for an effective transition towards UHC · 2017. 4. 18. · Building...
Transcript of Building institutions for an effective transition towards UHC · 2017. 4. 18. · Building...
1 |
Building institutions for an effective transition towards UHC
Dr Agnès Soucat
Health Systems Governance & Financing
WHO
Sustainability and Transition Meeting
30 March 2017
2 |
TRANSITION FROM AID
Many (most?) countries can expect a decline in aid
Others experience other types of transition: health financing,
epidemiological, demographic, economic, etc
Not a money issue ?
ALL countries need to strengthen public finance
Strengthening institutions is key
3 |
NOT A MONEY ISSUE?
4 |
”a transition in which the per capita amount of external
financing declines while indicators of (1) overall population
health and (2) overall access to health services do not
decline.”
Bill Savedoff
5 |
IS TRANSITION REALLY ABOUT MORE MONEY
Domestic and External Resources for
Health in Fragile States (2011-13)
Domestic and External Resources for
Health in non-fragile LICs (2011-13)
Sources:
1. OECD DAC2011-2013 (28 Fragile States, 10 billion constant 2013 USD/7.57 per capita, 26 non-fragile LICs (20 billion constant 2013 USD/10.45 per capita) : other includes donors who gave less than 100 M$; disbursement-base data to a country from a donor and not include multi-
country donations; World Bank “HARMONIZED LIST OF FRAGILE SITUATIONS FY15” was used for the fragile status.
2. WHO Global Health Expenditure Database (24 Fragile States, 24 non-fragile LICs): external resource represents health expenditure from external source as percentage of total health expenditure; domestic resource includes both private and public health expenditures
6 |
Public expenditure on health per capita in transitioning countries is above the lower-middle income average
UMIC average
LMIC average
0
500
1,0
00
1,5
00
2,0
00
2,5
00
Co
nsta
nt
201
1 in
tern
ation
al$
PP
P
Ba
ng
lad
esh
La
o P
DR
Tim
or-
Le
ste
Su
da
nN
ige
ria
Ph
ilip
pin
es
Ind
on
esia
Pa
pu
a N
ew
Gu
ine
aV
an
ua
tuG
ha
na
Syri
an
Ara
b R
ep
ub
licS
olo
mo
n I
sla
nd
sV
ietn
am
Uzb
ekis
tan
Arm
en
iaS
ri L
an
ka
Ge
org
iaG
ua
tem
ala
Nic
ara
gu
aK
irib
ati
An
go
laH
on
du
ras
Mo
ldo
va
Ca
bo
Ve
rde
Bo
livia
Gu
ya
na
Tu
rkm
en
ista
nB
hu
tan
Aze
rba
ijan
Sa
mo
aT
on
ga
Ja
ma
ica
Ukra
ine
Sw
azila
nd
El S
alv
ad
or
Alb
an
iaM
on
go
liaB
eliz
eG
ren
ad
aS
t. L
ucia
Do
min
ica
n R
ep
ub
licP
eru
Pa
rag
ua
yIr
aq
Do
min
ica
Ga
bo
nM
au
ritiu
sT
un
isia
Ira
n,
Isla
mic
Re
p.
St.
Vin
ce
nt
& G
ren
ad
ine
sS
uri
na
me
Ecu
ad
or
Bo
tsw
an
aN
am
ibia
So
uth
Afr
ica
Ma
rsh
all
Isla
nd
sM
ala
ysia
Tu
va
luK
aza
kh
sta
nA
lge
ria
Be
laru
sC
olo
mb
iaB
ulg
ari
aS
erb
iaT
ha
ilan
dR
om
an
iaC
osta
Ric
aP
an
am
aC
ub
a
Source: WHO Global Health Expenditure Database
Public expenditure on health per capita, 2014
UMIC average
LMIC average
7 |
Also as a share of GDP….
02
46
81
01
21
41
6
Perc
en
t
Tim
or-
Le
ste
Ba
ng
lad
esh
Ind
on
esia
La
o P
DR
Nig
eri
aA
ze
rba
ijan
Tu
rkm
en
ista
nP
hili
pp
ine
sG
eo
rgia
Su
da
nS
ri L
an
ka
Arm
en
iaS
yri
an
Ara
b R
ep
ub
licA
ng
ola
Gu
ate
ma
laM
ala
ysia
Ga
bo
nV
ietn
am
Ma
uri
tiu
sK
aza
kh
sta
nU
zb
ekis
tan
Mo
ng
olia
Gh
an
aJa
ma
ica
Gre
na
da
Ira
n,
Isla
mic
Re
p.
Do
min
ica
n R
ep
ub
licA
lba
nia
Su
rin
am
eB
ots
wa
na
Pe
ruIr
aq
Va
nu
atu
Ca
bo
Ve
rde
St.
Lu
cia
Be
laru
sB
oliv
iaD
om
inic
aN
ica
rag
ua
Ukra
ine
Be
lize
Tu
nis
iaE
l S
alv
ad
or
Ho
nd
ura
sS
ou
th A
fric
aT
on
ga
Bh
uta
nS
t. V
ince
nt
& G
ren
ad
ine
sG
uya
na
Sa
mo
aR
om
an
iaP
ara
gu
ay
Ecu
ad
or
Pa
pu
a N
ew
Gu
ine
aB
ulg
ari
aM
old
ova
Sw
azila
nd
Alg
eri
aN
am
ibia
Co
lom
bia
Th
aila
nd
So
lom
on
Isla
nd
sP
an
am
aS
erb
iaC
osta
Ric
aK
irib
ati
Cu
ba
Ma
rsh
all
Isla
nd
sT
uva
lu
Source: WHO Global Health Expenditure Database
Public expenditure on health as % of GDP, 2014
UMIC average
LMIC average
8 |
Still progress can be made to prioritize health in some transitioning countries
05
10
15
20
25
30
Pu
blic
exp
en
ditu
re o
n h
ea
lth a
s %
of to
tal go
vern
men
t exp
en
ditu
re
500 1000 5000 25000 75000GDP per capita, PPP 2011 $
Source: WHO Global Health Expenditure DatabaseRed signifies Global Fund or Gavi transition country
Public expenditure on health as % oftotal government expenditure versus GDP per capita, 2014
9 |
A PUBLIC FINANCIAL MANAGEMENT AGENDA
10 |
Focus on revenues AND expenditures
Health programs and their partners each addressing these issues and approaching Finance
Ministries
– …for sustainability of their program (HIV/AIDS, NCDs, NTDs, nutrition, RMNCAH, TB, malaria,…)
Sustainability is not only a revenue question; we also have to think about managing
expenditures to get better results from our spending
– “Can’t just spend your way to UHC”
Enabling efficiency
– Streamline system architecture across programs while ensuring good results
– Invest in underlying systems
11 |
WHAT TRANSITION IS REALLY ABOUT …
Enabling effective domestic revenue collection and allocation for the
sector
Managing expenditures better to get better results
Building or strengthening organizations and processes that support and
enable system efficiency and performance
Streamlining processes across programs to end fragmentation, while
ensuring good results
12 |
INSTITUTIONS
13 |
TRANSITION FROM MDGs to SDGs
MDGs stimulated fragmentation: separate plans, budget, funding,
procurement, monitoring, etc.
SDG targets may lead to continued emphasis on vertical approaches:
more separate plans, monitoring mechanisms, funding streams and
implementation efforts
How to avoid the same vertical trap? Health Systems for UHC
The UHC target can provide “umbrella” to enable move away from silos and
fragmentation
14 |
SDGs (Impact)
UHC (Outcome)
Health System Strengthening/ Performance (Input/Output)
Health System Strengthening
Achieve Universal Health Coverage All people and communities receive the quality health services they need,
without financial hardship
SDG 1: No poverty
SDG 4: Quality Education SDG 5: Gender Equality
SDG 16: Inclusive societies SGD 8: Inclusive economic growth
and decent jobs
SDG 3: Equitable health outcomes and wellbeing; Global public health security
and resilient societies
Investing in Health Systems to reach the SDGs
15 |
Fit for context – Fit for purpose
Health Systems
Building Health System Foundations
Strengthening Health System
Institutions
Supporting Health System
Transformation
16 |
Focus on increasing overall tax revenues at the core of transition agenda
05
10
15
20
25
30
35
Tax r
eve
nu
e a
s %
of G
DP
500 1000 5000 25000 75000GDP per capita, PPP 2011 $
Source: World Bank World Development IndicatorsRed signifies Global Fund or Gavi transition country
Tax revenue as % of GDP, 2014
17 |
Institution building (1): it is about citizens
Domestic funding is about citizens voice
Collective financing is driven by choices of taxpayers in terms of revenue generation, and
budget allocations
Efficiency is driven by accountability
18 |
Institution building (2): it is about the law
Strengthening critical regulation and legal frameworks
–Procurement
–Public Financial Management
–Human Rights and Entitlements
–Accreditation/Regulation of medical products
19 |
Building governance capacity of Ministries of Health --- often weakened by parallel governance structures – Not only policy capacity but also implementation capacity
– Norms, standards and regulation
– HTA and strategic purchasing
– Monitoring and evaluation
– Using evidence for policy; implementation research
Comprehensive, evidence-based health sector strategies, formulated through a participatory approach – Vertical programs integration
– Subsector (HRH, pharmaceuticals etc) integration
Institution building (3): it is about agencies’ capacity
20 |
Governance - Examples
Institutuional & legal assessment
Develop organizational capacity for reforms including
legal framework
Policy dialogue on accountability / “citizen’s voice” at
national, sub-national or local level (e.g. NHAs)
Design needed institutional reforms
Support setting institutional arrangements to better inform
policy
Annual transparent reviews
Financing - Examples
Health financing diagnostic analysis
Strengthening resource tracking methods and capacities
Diagnosing potential areas for technical efficiency gains
Advice on design & impl° planning for nat health
financing strategy
Institutional support to nat./Region public health/econ.
training entities
Health financing training
Workforce - Examples
Health Labour Market analysis
Support the development of health workforce strategies
aligned with NHPSPs
Support the inter-ministerial dialogue on health workforce
Support the development of curricula, pre-service and in-
service education programmes
Strength institutional capacity for HRH stewardship
Regulatory frameworks
Pharma./med. products - Examples
Policy dialogue on Good Governance of pharmaceutical
systems including regulation, procurement and supply
Policy dialogue on access to ess. medicines and health
products, incl. review of policy options for supply systems
& local production
Education and training of health care professionals in
order to support the implementation of national medicines
policies and strategies
Information - Examples
Policy dialogue to ensure availability and accessibility of
comprehensive disaggregated high-quality data
Support interoperability and integration of HIS systems
to reduce fragmentation and ensure communication,
exchange and use of health data (e.g. Nat Obs)
Strengthen analytical capacity and engage national stat.
offices to support MoH in monitoring SDGs
Service Delivery - Examples
Policy dialogue on national quality and safety policy and
strategy
Design and evaluate options to re-orient the model of
care and for successful care coordination
Support to hospital and public health institute
strengthening programmes
Support for key health systems functions in AMR national
action plans (e.g. antibiotic stewardship, infection
prevention, research and development)
Institution – examples of interventions
21 |
Transition is about Institutions
Not a money issue
ALL countries need to strengthen public finance
Strengthening institutions is key