Universal Health Coverage: How
does your (RBF or not RBF) solution
fare?
Bruno Meessen, ITM & PBF CoP
Expert Talk, Eschborn,
December 12th 2012
An assessment of the problem
• Health situation in LICs is unacceptable:
– Overall status (health / social protection);
– Inequity, esp. the poorest.
• Yet, we know pretty well the interventions
which are needed.
• Health system delivery is part of the problem.
USE OF BASIC MATERNAL AND HEALTH SERVICES
Coverage Rates among Lowest and Highest 20% of the Population in 56 Developing
and Transitional Countries (David Gwatkin, 2007)
100
90
80
70
60
50
40
30
20
10
0
Antenatal Care
Oral
Rehydration
Thereapy
Full
Immunization
Med.
Treatment of
Ac. Res. Inf.
Lowest 20% of Population
Att. Delivery
Med.
Treatment of
Fever
Highest 20% of Population
Modern Contra.
Use (Women)
Contribution to UHC as the bottom line
“Everyone should be able to access health
services and not be subject to financial hardship
in doing so”. (WHA resolution 58.33 2005).
Could one structure a bit the contribution of a
scheme / initiative / solution to UHC?
The 12 desirable traits of any potential
solution
• Such a solution builds the path to universal coverage, by:
Increasing direct benefits to the priority groups.
• (1) Increasing resources to health.
• (2) Reducing barriers, especially for the most vulnerable groups.
• (3) Paying attention to quality of service in public facilities.
• (4) Enhancing an efficient use of resources.
• (5) Paying attention to quality of care, across the board.
• (6) Protecting against impoverishment.
Consolidating the system.
• (7) Fixing ‘health system problems’.
• (8) Being harmonious with other health strategy.
• (9) Not undermining control by national health authorities…
• (10) But improving their accountability and contribute to overall better governance.
• (11) Being scalable, sustainable and appropriate as a stage in a long-term process.
• (12) Consolidating the political momentum for UHC and rights to health.
(1) Contribute to resource mobilisation
• Does the solution increase altruism/solidarity, trust and financial
commitment by tax payers, Ministry of Finance, donors and tax payers
from the North?
• Does it enhance disbursment of the allocated budget?
• Ideal features:
–
–
–
–
–
Predictibility.
Deliver benefits (in kind or cash) directly to target groups.
Traceability.
Complete contract.
Mismanagement-proofed.
• NB: (1) the environment has changed; (2) the future of health care
financing in most LICs is national resources (domestic revenue).
(2) Remove barriers faced by the users,
and the most vulnerable in particular
• Quite poor performance of the dominant model (NHS
with free preventive services and user fees for curative
services). Cf. David Gwatkin analyses.
• Can the solution target resources (if needed)?
• What is its scale?
• Does the solution address remaining barriers on the
demand side, at least for the most vulnerable?
–
–
–
–
Out-of-pocket payment for curative services.
Distance.
Transport.
Knowledge.
(3) Improve quality of services
• The role of barriers on the supply side is underestimated.
Their vulnerability to health facility managers as well.
• Will the solution bring about improvements in terms of:
–
–
–
–
–
–
–
–
Availability of qualified staff.
Availability of drugs.
Cleanliness.
Opening hours.
Friendliness.
Queues.
Respect of dignity.
…
(4) Improve efficiency
• Value for Money is not an agenda of donors only.
Cf. Kaberuka 2011.
• This is a requirement for all resources – including
private and public resources.
• Does the solution contribute to greater :
– Allocative efficiency (promote high impact
interventions).
– Technical efficiency (get the maximum from the staff,
equipment and infrastructure).
– ‘Transactional’ efficiency (limited transaction costs)
(5) Improve quality of care
• Efficiency requires effectiveness of treatment.
Quality of care is a huge problem in many LICs,
across the board.
• How does the solution address quality of
care?
– Keep in mind that quality of care has many
determinants, some can be influenced by health
facility managers. Some components are verifiable
ex ante, some ex post, some are not.
– What about the Private for Profit providers?
(6) Reduce risk of impoverishment
• How does the solution protect against
catastrophic health care expenditure and
income loss / iatrogenic poverty?
• In the public sector, but also in the private
sector. => It is about insurance, but also
regulation of providers and shaping health
seeking behaviours.
Many interventions show some of
these 6 traits. But a UHC friendly
solution should also fulfill 6 other
‘systemic’ requirements.
(7) Address structural health system
problems
• Does the solution contribute to
– Better performance by the public facilities, support
services (e.g. drug supply) and administration (e.g.
SIS);
– Fair treatment of the private not for profit;
– Harnessing the private for profit providers?
• Some interesting tracks:
– Voice and exit mechanisms, separation of functions,
clarification of missions, contract, purchaser-provider
split, autonomy, neutrality to ownership of the
providers, independent verification, measurement,
sanction.
(8) Harmonization with other
interventions
• Many ways to respect the first 6 components.
• Is your solution in line with other
interventions respecting the 6 traits? Does it
help to counter / correct solutions which do
not respect the 6 first traits?
• A particular risk for UHC: multiplication of
schemes; vertical approaches; loss of the main
objective.
(9) Consolidate leadership by the
Ministry of Health
• The solution should not be forced from
outside. Political and technical leadership by
national authorities is needed for
sustainability, but also as a mechanism to
ensure (8).
• Is the solution implemented in such a way
that it empowers the MoH (esp. in donor
dependent countries)?
(10) Contribute to overall better
governance
• Trait 9 should not conflict with accountability to
citizens.
• Poor performance of the health sector is indeed
also the outcome of constraints outside the
sector, including lack of accountability.
• The solution should combat/shortcut
embezzlement and fraud; care for transparency;
resist pressure from vested interests by
establishing a culture of policy experimentation,
monitoring and evaluation.
(11) Scalability, sustainability and path
dependency
• Is the solution scalable, sustainable and putting
the health system on a good path?
• Scale: can you ensure that all individuals
belonging to the target group are covered?
• If sustainability is required, can the solution be
integrated in public funding and operated by
national actors?
• Path dependency: how does the solution affect
the balance of power for stakeholders such as
insurees, providers, private insurance funds,
pharmaceutical sector…?
(12) Consolidating the UHC momentum
• We are technicians, but UHC is about politics.
Cf. Thailand, Rwanda, Venezuela!
• Does the solution get visibility at voter level?
Political pay-off?
• Does it consolidate rights to health?
Our rough assessment
• Many RBF solutions score pretty well on these
12 traits.
• Some RBF approaches score better than some
others on some traits.
=> How do others think about this?
RBF, strategic purchasing and the agenda
of health financing for universal coverage
 Efficiency (more health for the money) as one of the key
pathways to Universal Coverage identified in WHR2010
 Strengthening purchasing is a key to building domestic
health financing systems
– It means using information on provider performance or
population health needs to drive resource allocation
– Builds capacity; people have to analyze and use this
information for decision-making
– Changes system culture, shakes up bureaucratic inertia
 RBF – PBF – P4P etc. are all examples of strategic
purchasing
20 |
HF for UHC concepts, principles, lessons
BTC Brussels, 3 December 2012
Joe Kutzin
As with health insurance schemes, think
from scheme to system with PBF
 PBF/RBF should not be run like a "scheme" or "project",
but as a step in the process of moving systems towards
more strategic purchasing
– Long-term capacity building for the purchaser (and investing in
understanding by the providers) is much more important than
trying to "prove" whether it works or not (because we know that
passive budgeting or unmonitored fee-for-service does not
work)
21 |
HF for UHC concepts, principles, lessons
BTC Brussels, 3 December 2012
Joe Kutzin
A bad RBF project…
 …is run by donors (or institutionalizes the idea that the
money for these incentives will be managed separately)
 …overdoes the financial incentives in a way that can't
be sustained by the government
 …is only interested in "proving that it works" in the short
run, rather than always acting with the intent to move
from scheme to system
 …overwhelms domestic capacity with too many new
things to monitor
 …does not address the institutional platform that will, in
the future, be required to attract and retain the people
with the necessary skills to be good purchasers
Joe Kutzin
Operation: our assessment
1. RBF can be a tool for bilateral aid to
contribute to UHC.
2. Bilateral aid can help in trying out new
strategies.
3. Coordination will be key.
• Thank you.