Health Financing in Africa: More Money for Health or Better Health - - PowerPoint PPT Presentation

Health Financing in Africa: More Money for Health or Better Health For the Money?

March 8 , 20 10

AGNES SOUCAT,MD,MPH,PH.D

LEAD ECONOMIST ADVISOR HEALTH NUTRITION POPULATION AFRICA

WORLD BANK

Harmonization For Health in Africa

Harm onization For Health in Africa

OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA’S INNOVATIONS IN HEALTH FINANCING FROM HERE TO THERE

Harm onization For Health in Africa

OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA’S INNOVATIONS FROM HERE TO THERE

Harm onization For Health in Africa

Maternal Mortality Rem ains Very High in SSA

‹#2›

150 500 900 45

100 200 300 400 500 600 700 800 900 1000

East Asia & Pacific South Asia Sub‐Saharan Africa China Per 100,000 live births 2007

Source: World Development Indicators

Harm onization For Health in Africa

Most countries in SSA are off track to reach MDG5

Harm onization For Health in Africa

Most SSA countries spend less than US$50 per capita on health

Harm onization For Health in Africa

Som e Countries Have Problem s Accom m odating even a Basic Package of Services

Harm onization For Health in Africa

More than half of health expenditures in SSA are private

Out of Pocket Spending dom inates private financing in m ost countries

External aid is an im portant source

• f health spending in Sub-Saharan

Africa

External aid as % of total health spending (2002)

2 4 6 8 10 12 14 16 18 20 East Asia & Pacific Eastern Europe & Central Asia Latin America & the Caribbean Middle East & North Africa South Asia Sub-Saharan Africa

Region

Percent of total health expenditure

Harm onization For Health in Africa

Six years to the MDGs

The MDGs horizon is six years away: what are the

low hanging fruits? What is most effective ? What can be quickly scaled up?

The health sector does not produce results. Why is

it? It does not need to be so: some countries are doing much better than others..

Some countries give very little priority to

health..why? What needs to be addressed?

‹#2›

Harm onization For Health in Africa

Critical issues to be addressed

Fragmentation and donors’processes disconnected from

country processes

Planning and Budgeting not based on evidence and

analysis of country specific constraints to delivering high impact interventions

Public money benefits richer groups Public Financial Management frontline providers do not

have resources (PETS)

Post colonial civil service models reach their limits.

Dramatic lack of linkage between performance and incentives..

Harm onization For Health in Africa

OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA’S INNOVATIONS FROM HERE TO THERE

Rwanda

A small country in

Central Africa

Genocide in 1994 In 2005 , 4/ 10 births

attended by a health professional.

Infant Mortality : 86

per 1,000

HIV : 3.1%

Source: Rwanda 2005: results from the demographic and health survey. 2008. Studies in family planning, 39(2), pp. 147-152.

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Rwanda

Shortage of human resources for health services No cash resources in health facilities Low levels of productivity and motivation among

medical personnel

Low user satisfaction & poor quality of service leading

to low use.

Rwanda has undertook m ajor reform s to strengthen accountability of all institutional and individual actors for MDGs related results...

• Fiscal Decentralisation with strong governance

structures and community participation.

• IMIHIGO: Performance contracts between President of

the Republic and mayor of Districts;

• PBF: Performance Based Financing;
• CBHI: Community Health Insurance;
• Autonom y of health facilities, including hiring and

firing of health personnel;

..through a shift of paradigm ..

NATIONAL GOVERNMENT

LOCAL GOVERNMENT

AUTONOMOUS FACILITIES PROVIDERS Clients / Citizens

VOICE CLIENT POWER

Performance CONTRACTS

COMMUNITY HEALTH WORKERS PROVIDERS COMMUNITY HEALTH INSURANCES Mutuelles COMMUNITY GOVERNANCE Umushyikirano, Citizen Report Cards, Ombusdman

PERFORMANCE BASED, CASH AND IN KIND INVESTMENT INPUT SUBSIDIES TRANSFERS

Strengthening accountability in the health sector in Rwanda

Under five mortality trends with MDG target for 2015

50 100 150 200 250 1999 2001 2003 2005 2007 2009 2011 2013 2015

U5MR per 1,000

1990 level MDG target for 2015 Observed Trends since 1998 Trends required to reach the 2015 target

Results show Rwanda is now back on track towards the health MDGs…

All incom e groups benefit although inequities still persist …

Under five mortality trends by income quintile (2005-2007)

211 195 170 204 122 161 149 132 141 84 50 100 150 200 250 Poorest Quintile 2 Quintile 3 Quintile 4 Richest U5M R per 1,000

DHS 2005 DHS 2007

Source: DHS 2005 and 2007.

Harm onization For Health in Africa

Rwanda: Coverage with MDGs High Im pact Interventions increases

10 20 30 40 50 60 70 80 90 100 % delivered in a health facility TOTAL DPT3 (%) Currently Using any modern FP method (%) % U5 who slept under an ITN the past night % 2000 2007

Increase in utilization of assisted deliveries

Trends in assistance at delivery : Years 2000, 2005, 2007. Percentage (%) of women delivered by a health professional

Decentralization

Administrative, fiscal

and financial decentralization has provided large sums of money to local levels of government and given them much flexibility by providing them with block grants

Fiscal and Financial Decentralization

10,000,000,000 20,000,000,000 30,000,000,000 40,000,000,000 50,000,000,000 60,000,000,000 70,000,000,000 Disbursed 2002 Disbursed 2003 Disbursed 2004 Disbursed 2005 Budget 2006 Projected 2007 Year A m o u n t i n R W F Transfers to Districts CDF Transfers to Provinces

Total health personnel in publicly funded facilities has alm ost doubled in 3 years …

Source: Public Expenditures Review Rwanda; 2005

Financing has m ore than tripled in four years (going from USD 7.5 to 30 .3 m illions, of which the PBF has grown m ore than tenfold from USD 0 .8 to 8 .9 m illions) Source: Public Expenditures Review Rwanda; 2005

Harm onization For Health in Africa

Health Insurance in Rwanda

Micro-Insurance model with two levels of re-insurance funds Tax subsidy and crossusbidy from formal sector insurance Rapid increase in enrollment from 7% in 2003 to 91% in 2008 Mutuelle enrollment significantly improves access to health care at all

income levels, including the poorest – and reduces inequality in access, particularly among the top four quintiles.

Mutuelle enrollment significantly reduces the risk of catastrophic

health expenditures.

Rwanda: Scaling up of com m unity health insurance

Proportion of individuals enrolled in health insurance

10 20 30 40 50 60 70 80 90 2002 2003 2004 2005 2006 2007 2008 %

Source: MOH Rwanda; 2005 EICV 2005

At all incom e levels, those enrolled in “m utuelles” are m uch m ore likely to use health services.

DHS 2005 8 93 35 27 96 77 11 97 42

10 20 30 40 50 60 70 80 90 100

Use of contraceptives, 15-49 years At least one ANC Delivery assisted by skilled professional % use of reproductive health services None RAMA Health mutuelle

Harm onization For Health in Africa

Perform ance-based Financing (PBF)

Developed after extensive piloting from 2001-

2005

Objectives

Focus on maternal and child health as well as communicable

diseases (MDGs 4 & 5)

Increase quantity and quality of health services provided Increase health worker motivation

Financial incentives to providers to see more

patients and provide higher quality of care

Operates through contracts between

Government Health facilities providing services

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Harm onization For Health in Africa

Table 1: Output Indicators (U’s) and Unit Payments for PBF Formula

OUTPUT INDICATORS Amount paid per unit (US$) Visit Indicators: Number of … 1 curative care visits 0.18 2 first prenatal care visits 0.09 3 women who completed 4 prenatal care visits 0.37 4 first time family planning visits (new contraceptive users) 1.83 5 contraceptive resupply visits 0.18 6 deliveries in the facility 4.59 7 child (0 - 59 months) preventive care visits 0.18 Content of care indicators: Number of … 8 women who received tetanus vaccine during prenatal care 0.46 9 women who received malaria prophylaxis during prenatal care 0.46 10 at risk pregnancies referred to hospital for delivery 1.83 11 emergency transfers to hospital for obstetric care 4.59 12 children who completed vaccinations (child preventive care) 0.92 13 malnourished children referred for treatment 1.83 14

• ther emergency referrals

1.83

Harm onization For Health in Africa

36.3 49.7 34.9 55.6

30.0 40.0 50.0 60.0 Baseline (2006) Follow up (2008) Proportion of of institutional deliveries

Control facilities Treatment (PBF facilities)

7.3 % increase due to PBF

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Delivery at the health facility increased overall in Rwanda, but 7% m ore in PBF facilities between 20 0 6-20 0 8 ….

Harm onization For Health in Africa ‐0.10

‐0.13 0.15 ‐0.15 ‐0.10 ‐0.05 0.00 0.05 0.10 0.15 0.20 Baseline (2006) Follow up (2008) Standardized Prenatal effort score

Control facilities Treatment (PBF facilities)

15 % Standard deviation increase due to PBF

32

In the last years, PBF has increased prenatal care quality significantly …

Harm onization For Health in Africa

OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY .. RWANDA’S INNOVATIONS FROM HERE TO THERE

Harm onization For Health in Africa

MDGs are am bitious: scaling up will be challenging to im plem ent

SSA Countries require increased and better allocated

domestic and external funding for strengthening their national health systems in order to achieve the MDGs.

Most resources are to come from countries’

contributions:

need for domestic advocacy to raise attention to national budgeting

processes

Need to channel private spending into risk pool

Importance for external aid to be catalytic: need to focus

• n results and efficiency gains

Harm onization For Health in Africa

Evolution of Health Financing Systems

Patient Patient Out Out-

• of
• f-
• Pocket

Pocket Social Social Insur Insur Gov Gov’ ’t t Budget Budget Gov Gov’ ’t t Budget Budget Social Social Insur Insur Patient Out Patient Out-

• f
• f-
• Pocket

Pocket Priv Priv. . insur insur

Low Income Low Income Countries Countries Middle Income Middle Income Countries Countries High Income High Income Countries Countries National Health National Health Service Service Social Social Health Insurance Health Insurance Private Private Insurance Insurance

Source: Modified from A. Maeda

Community Community Financing Financing

Patient Out Patient Out-

• f
• f-
• Pocket

Pocket

Government Government Budget/MOH Budget/MOH

Harm onization For Health in Africa

Making private m oney m ore efficient: Health Insurance

As out of pocket spending has been growing

recently, the need for pooling emerges as a main policy priority in SSA

Two African countries (Ghana and Rwanda) are

achieving ground breaking success on health insurance pushing the limits of the innovation “frontier”

These countries demonstrate that it is possible to

achieve rapid scale up of healh insurance with actual effect on health utilization and income protection

Harm onization For Health in Africa

Making public m oney m ore efficient: Results Based Financing

Purchasing of results and outputs replacing input based financing Promising results in Afghanistan, Burundi, DRC, India, Haiti, Nepal,

Zambia

Adopted and initiated in Benin, Ghana, Eritrea, Ethiopia, Scaled up in Rwanda and positive results from rigorous Impact

Evaluation

Harm onization For Health in Africa

Conclusion

With the MDGs finish line in view, a strong dialogue

between MOH and MOF is more needed than ever

Dialogue can be centered around the production of

results: the health sector can do it

Both supply and demand side financing need to be

tapped

Some hard issues need to be tackled: budget reform, a

new vision for public workers, PFM reform around decentralization, autonomy and results focus

Harm onization For Health in Africa

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THANK YOU!