Regional Conference of Sector Network Health & Social Protection
Africa, MENA and LAC
Towards UHC in Africa
How to argue for increased domestic
resources?
Kai Straehler-Pohl | Sector Project P4H, Germany
6-9. May 2014 | La Palm Hotel, Accra/Ghana
Africa on the move – Countries moving towards UHC
HFS/UHC/SHP Processes
GIZ/P4H supported process
… but one challenge remains:
How to get the Ministry of
Finance on board for a
substial budget increase?
P4H supported process
Other known processes
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
Part 1: The necessary condition
Arguments that you should invest
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The intrinsic value: Health as a human right
• "Everyone has the right to a standard of living adequate for the
health and well-being of himself & of his family, including […] medical
care […]." Art. 25 Universal Declaration of Human Rights, 1948
• “… the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health […] assure to all medical
service and medical attention in the event of sickness” Art. 12
International Covenant of Economic, Social and Cultural Rights, 1966
General comment No. 14 (ECOSOC, 2000):
… a set of both freedoms and entitlements
which accommodate the individual's biological
and social conditions as well as the State's
available resources, both of which may
preclude a right to be healthy for reasons
beyond the influence or control of the State…
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The instrumental value: Health generates wealth
Wordle from: Harmonization for Health in Africa (2011): Investing in Health for Africa: The Case for Strengthening Systems for Better Health Outcomes. Chapter 3 – The wider
investment case.
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The instrumental value: Health generates wealth (2)
• Health increases productive years – fewer life years lost increase life
expectancy lengthens active working age
 11% of L/MIC growth 1970-2000 (Jamison et al. 2005)
• Health increases labour productivity – especially in manual labour in
largely agricultural economies such as many African economies
• Health brings investments in education – lower absence times of
pupils and free funds to invest in household budgets
• Health lowers dependency ratio – lower child mortality typically
leads to lower birth ratios and thus higher pop share at working age
• Health shifts consumption – frees up money and increases markets
for other goods
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The instrumental value: Health generates wealth (3)
• Health increases investments – people live longer, save/invest more
to cater for the future, whether through social or traditional systems
• Health increases ROIs – lower risk of illness allows higher risk
economic investments that are typically more profitable
• Health stabilizes workplaces – fewer deaths lead to lower staff
turnover and increase productivity
• Health can increase FDI – in some sectors some diseases (e.g.
tourism and Malaria) are immediate obstacles to foreign investments
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
Lower fertility and lower
child mortality
Improved child health
and nutrition
Increased ratio of
workers to dependants
Higher GDP
per capita
Increased labour
productivity
Increased school
attendance and
cognitive ability
Adapted from: Ruger, Jamison and Bloom (2002): WG report 1 of The Commission on
Macroeconomics and Health.
Larger labour force from
increased survival and
later retirement
Improved adult health
and nutrition
Increased access to
natural resources and
global economy
Increased investment in
physical capital
Higher attractiveness for
FDI
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The combined argument: Health is wealth
• Premise: GNI/GDP is not an appropriate goal dimension
• Worldwide: Human Development Index
• Income, Life expectancy, education (indeces)
• Bhutan: Gross Happiness Index
• Economic, environmental, physical, mental, workplace, social,
and political wellness – mostly measured through direct survey
• World Development Report:
• Disability adjusted life years (DALYs) – morbidity adjustments to
life expectancy
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The combined argument: Health is wealth (2)
• Lancet Commission Global Health 2035: “Full income” approach
 people value additional life year and reduced mortality risk
 1 yr additional life expectancy = 2.3 annual income in L/MIC
• Full income = f(economic income, mortality risk)
 decrease mortality risk = increase in full income
• 33-50% of “full income” growth is from reduction in mortality risk
• UHC with highly cost-effective interventions in 2035 = -9.3 m deaths
 ROI of Universal Coverage with highly cost effective interventions:
 34 low income countries: 900% (~65% HSS costs)
 48 middle income countries: 2,000% (~35% HSS costs)
• Note: Expansion of approach to morbidity (e.g. DALYs) would increase
estimated return – but reopen ethical debate on value of life
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
Part 2: The sufficient condition
Arguments that the investment will pay off
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The performance argument: Monitoring results
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Premise: Good results provide positive incentives for taking action
Measure impacts/outcomes:
• Health: Demographic and Health Surveys (DHS), SAGE; Downside: no political
driver due to typical 5 year cycle
• Financial protection: Household income/expenditure/budget surveys; downside:
no political driver due to typical 5 year cycle
Measure outputs:
• Health: Health Management Information Systems to measure health service
utilization (proxy attractiveness and access); downside: utilization can also be a
sign of bad health
• Finance: National Health Accounts – OOPs; downside: often not disaggregated by
equity / incomes
Measure inputs:
• Health system: Service Availability and Readiness Assessments/Mappings
• Financial: National Health accounts, Public Expenditure Reviews
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The value-for-money argument: Doing the right things right
• Allocative efficiency reforms:
• Investing in highly cost effective interventions – the benefit
package design
• Letting the money follow patients – payment system design (pt. 1)
• Technical efficiency reforms:
• Creating incentives for frugality – payment system design (pt. 2)
• Allowing managers to manage – taking decisions where
information on inefficiencies is
• Building capacity for managers – making sure that managers are
equipped to take decisions
• Monitoring: Public Expenditure Tracking Surveys; Social Audits
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
The performance argument: incentives to improve
• Riding the wave – performance/results-based financing is in fashion, so
use the words to promote any output-based payments systems…
• Using “standard” PBF to complementing other reforms
• Use to translate policy priorities into action (as with all priority
setting, negative side-effects need to be monitored)
• Reward process indicators where “market failures” exist (e.g. data
is often only useful when aggregated, so individuals fail to provide)
• Efficiency-based local savings are a good source for local incentive
schemes (but only if maintenance of standards is controlled)
• Reward directly your objective – staff redistribution (e.g. to rural
areas) via PBF may backfire
Regional Conference of Sector Network Health & Social Protection | Africa, MENA and LAC
Regional Conference of Sector Network Health & Social Protection
Africa, MENA and LAC
THANK YOU!
kai.straehler-pohl@giz.de
6-9. May 2014 | La Palm Hotel, Accra/Ghana