Health Financing in Low Income Countries

Transcription

1 Engaging on health financing - A guide 1

2 This guide has been written by Nouria Brikci, Health policy and advocacy adviser, Save the Children UK and Clare McIver, policy adviser, Merlin 2

3 Contents 1. Purpose of this guide 2. Merlin s and Save the Children UK s policies on health financing 3. An overview of the different health financing mechanisms 4. Planning your engagement on health financing 5. Country case studies 6. Conclusion 7. Further reading 3

4 1. Purpose of this guide In many low-income countries and fragile environments, access to essential healthcare is patchy and problematic for the majority of the population. The situation is particularly acute for the most vulnerable. Many governments in low-income countries and fragile environments are currently exploring strategies to increase resources for health, thereby improving access to essential healthcare. There are two main sources from which to raise additional funds: Internal country financing mechanism(s) International donors (though this source is rarely predictable, sustainable or substantial enough to provide for all the recurrent costs of healthcare). Merlin and Save the Children UK need to engage with the debates around which financing mechanism(s) to adopt, and they need to ensure that the strategies implemented improve access to essential healthcare. This guide responds to requests from staff working in low-income and fragile environments` to support their policy engagement in their country s health financing debate. It is designed to give a brief overview of the different financing mechanisms that a country can use, exploring their advantages and disadvantages, and providing links for further reading. It also gives tips on how to engage at the policy and programme level in country and sets out some key questions to consider when deciding whether or not engaging in these debates should be a central part of a country programme s approach. We hope this guide will help you feel empowered to engage at the policy level with these debates. For any further support, don t hesitate to contact your relevant head office or country level staff. Merlin and Save the Children This guide is based on the experiences of Merlin and Save the Children UK. It should be considered alongside other publications and briefings on health financing that they have produced. Merlin and Save the Children UK have developed this guide together as our approaches to health financing are similar and we hope this process will also encourage country level collaboration. 4

5 2. Merlin and Save the Children UK s policies on health financing 2.1 Merlin s approach to health financing In 2007, Merlin published its policy on health financing. The policy is based on analysis of the general context and experience gained from Merlin s programmes. Broadly, Merlin s policy is that: Everyone should have access to the healthcare they need, when they need it. The goal of Merlin s programmes is to work towards universal access in all countries. This requires all countries to have a health financing system that supports access to appropriate and effective healthcare, at an affordable cost. An appropriate health financing system ensures a number of key functions: It provides sufficient funding to allow all individuals to access a basic package of essential health services, while at the same time protecting them from any catastrophic medical expenses. It ensures that revenues collected are pooled within the population in a way that supports equity and efficiency. It ensures that health services are purchased in a way that promotes efficiency in the choice of services and equity in the way they are allocated across the population. For a detailed explanation of Merlin s policy, refer to: Save the Children UK s approach to healthcare financing Save the Children UK has engaged on health financing policy issues for many years now. The overall goal is to ensure: Universal coverage of a basic package of quality health services available free at the point of use. Save the Children believes that contributions to healthcare costs should be raised through progressive, universal mechanisms, in ways which ensure that contributions are equitable according to wealth or income. These resources should then be pooled and distributed fairly according to the population s needs. Healthcare should be available to all based on clinical need, completely disassociated from wealth or income. Save the Children UK has published various policy briefs and reports on health financing, available at There are many different approaches to financing healthcare, which are outlined in section 3. Save the Children UK s policy and advocacy has focused particularly on user fees in the past 5

6 few years. Based on the available overwhelming evidence 1, Save the Children UK unequivocally advocates against user fees/cost recovery systems, arguing that healthcare should be available free at the point of use. Save the Children UK has also published a guide to removing user fees, Freeing Up Healthcare, available on How should the health system be financed? While in this guide we only focus on internal country financing mechanism(s), such as taxes and direct payments for healthcare, we recognise the crucial role that donor funding plays, and must continue to play. Yet the complexity of health financing policy discussions lays in country financing mechanisms, hence the focus of the following section. 3. An overview of the different health financing mechanisms Healthcare systems are financed in a variety of ways, using public and/or private methods. To date, no low-income country or fragile environment has adopted a single or uniform health financing mechanism applicable across its whole country. Below is an outline of the main financing mechanisms, and their advantages and disadvantages in low-income countries and fragile environments. For more information, refer to the links throughout this section and the reading list in section Public methods of financing healthcare A publicly financed health system means that the main source of funds comes from the government (collected by pooling public money). The two options are tax-financed or social health insurance schemes A tax-financed system A tax-financed system is one where the government raises revenues through various forms of compulsory taxation to finance government healthcare expenditures. Positive features Payments are related to income rather than past or current risk (ie, whether you were or are likely to be ill). Payments are progressive the more you earn, the more contributions you make. 1 Go to Save the Children UK s website ( or look at external academic literature (available on request and in links provided in section 7). 6

7 Compared with other approaches, this approach can create the largest financial and risk pools. 2 This means it will collect the most funds and allow cross-subsidisation between rich and poor people, and healthy and sick people, promoting an equitable system. This approach is based on a pre-payment system, ie, people pay at various times throughout the year, unrelated to sickness, which avoids any type of cost being incurred when sickness occurs. Negative features Overview Low-income countries or fragile environments tend to have a large informal labour sector and therefore it is often difficult to collect taxes as people s incomes are not known or not collectable in practice. This may result in limited revenue being raised, although there are examples of innovative approaches to taxing the informal sector (see the Ghanaian example below). Although it is a progressive 3 mechanism for tax collection, the distribution of these funds also needs to be progressive, otherwise it can result in a system that is regressive 4 overall. Setting up, implementing and monitoring this system requires a strong government administrative structure, which is often lacking in low-income countries and/or fragile environments. However, this can be addressed over time and should not deter from implementation. A tax-based system is the most progressive approach to financing healthcare if funds are collected and distributed on an equitable basis; This is not a short-term solution. It needs to be planned for the medium to long term. For the short term, other financing mechanisms may need to be considered. Raising taxes from the informal sector in Ghana One barrier to a tax-funded system that is often cited is that it is difficult to collect tax (and therefore raise revenue) from those outside the formal sector. Ghana has been innovative in its attempt to widen the tax base to include the informal sector. The government delegated responsibility for collecting income tax from informal passenger transport operators (e.g., private bus companies, to their union. The scheme was quite easy to administer as the unions had detailed knowledge of their members activities so could easily collect taxes. Operators were liable for taxes only on the days they actually worked and taxes were collected at the lorry park; the union received 2.5% share of the total collection. The government has also sought to determine VAT obligations by checking the registration of the value of vehicles. 2 Risk pools are where the financial risks associated with future costs of healthcare and/or individuals health risks of becoming ill are shared among a group of people, rather than borne solely by the individual. This allows cross-subsidisation between low- and high-risk groups. 3 Progressive taxation is a tax where the rich pay a larger fraction of their income than the poor. 4 Regressive taxation is a tax where the poor pay a larger fraction of their income than the rich. 7

8 What the research says Equitap, a network of academics, looked into tax-financed health systems and found that overall where general tax funding mechanisms are the predominant form of financing healthcare (such as Hong Kong, Thailand or Sri Lanka), the pattern of health financing is more progressive than in countries dominated by a mandatory social health insurance system (See Health insurance There are three main types of health insurance available in low-income countries and fragile environments. One is public (social/national health insurance) and two are private (private and community-based health insurance). Social health insurance Social health insurance is an insurance programme which meets at least one of the following three conditions: Participation in the programme is compulsory either by law or by the conditions of employment The programme is operated on behalf of a group and restricted to group members An employer makes a contribution to the programme on behalf of an employee 5. Positive features Relate the initial payment to income rather than past or current risk ( ie, whether you were or will be sick); Payment is income related and progressive, which means the more you earn, the more tax you pay; This is based on a pre-payment system ie, people will pay at various times throughout the year, independently from sickness, which avoids any type of cost being incurred when sickness occurs. This approach can increase pooling, both financial (ie, raise substantial revenue) and risk (i.e., allows for cross-subsidisation between the rich and poor, healthy and sick). Negative features Social health insurance is usually linked to employment and therefore, in the main, only applies to people who work in the formal sector. People in the informal sector or who are unemployed are not usually covered (although in Kenya, contributions and benefits are open to people in the informal sector). Many low-income countries only have a small formal sector and therefore a social health insurance system would only apply to a small percentage of the population. This approach can create a two-tier health system, with those protected by the insurance accessing better quality care than those unprotected. 5 European Observatory on Health Systems and Policies glossary; accessed on 7 April

9 Overview Setting up, implementing and monitoring the system requires a strong government administrative structure. Such structures are often lacking in low-income countries and/or in fragile environments, although this can be remedied Social health insurance is a potentially progressive approach to financing healthcare. In low-income countries this proposed approach is popular at the moment. However, it s important to be careful about its pitfalls and develop systems alongside it to ensure a greater proportion of the population are protected and that it promotes equitable access. Note: Compared with social health insurance, national health insurance systems refer to a universal insurance system where the entire population as opposed to a specific group are covered, independently from contributions, and generally with heavy government subsidisation. This has the advantage of pooling the whole population s risk and resources, rather than the risk and resources of only, for example, the formal sector workers or other selected groups as in social health insurance. However, the pool of resources will remain smaller than that of tax-financed systems. Social health insurance in Ghana Ghana s social health insurance scheme was introduced in 2003 and has been operational since The scheme covers between 45% to 60% of the entire population, which is a definite improvement from the previously dominant user fees scheme. However, there are concerns about the equity of this approach (only 29% of the poorest are enrolled, against 67% of the richest) and the fact that the scheme relies heavily on subsidisation from tax revenues for 70 75% of its revenue. 3.2 Private methods of financing healthcare User fees User fees are payments patients make for healthcare services when seeking medical help. Positive features If there are absolutely no other forms of accessing healthcare, paying for care can ensure that at least minimum health services are available (as long as you can afford the services). Exemption systems can be developed in conjunction with user fees for the poorest or most vulnerable, eg, mothers and children, and therefore can mean that these groups have access to services for free. Negative features Only those who can afford to pay for healthcare receive it. User fees therefore create enormous access issues and are considered one of the most regressive (poor 9

10 Overview people pay proportionally more of their income for their healthcare) and inequitable forms of financing healthcare. Episodes of ill health can push households further into poverty or debt and can force households to make decisions between different vital services and goods eg, health vs. education or food. Very limited revenue is raised through user fees (average 5% of recurrent expenditures, net of administrative costs and sometimes the administration of the user fees system can cost more than the revenue raised. Exemption systems are very difficult to put in place and monitor, particularly those based on poverty levels. Consequently there are very few exemption systems that are effective (some successes have been documented where exemption systems target particular groups such as under five children and/ or women see Burundi example below). User fees often cause governance problems around the management of user fees at facility level. User fees or cost recovery systems are inequitable and efforts should be made to replace them with a mechanism that is more equitable and enables greater access. User fees in Burundi Burundi s health system was financed through a combination of user fees, social health insurance and taxes, with user fees being the dominant source of funding. Various studies showed the negative impact that user fees have on access to healthcare. For example, the user fees resulted in about 80% of the population being unable to access health services or were pushed into poverty as a result of payments. The government since decided to remove fees for under fives and pregnant women. As a result there has been an increase in use by these groups. For example in 2009, 146% more babies were born in health facilities compared with 2005 (Yates 2010 need a list of references at the back). For more information on this go to Community-based health insurance (CBHI) There are many different types of CBHI schemes (referred to as mutuelles in Frenchspeaking countries), and no agreed definition. Generally they have three characteristics: voluntary (as opposed to compulsory as social or national health insurance) not-for-profit (as opposed to for-profit as in private health insurance) community-based (as opposed to national as in social health insurance or national health insurance). Positive features CBHI is based on a pre-payment system ie, people will pay at various times throughout the year, independently from sickness, which avoids any type of cost being incurred when sickness occurs. 10

11 This approach provides some risk pooling for the selected population and is therefore an improvement from user fees. Payment is related to income rather than past or current risk, which means that people pay their contribution unrelated to whether or when they are sick. It provides a potential mechanism for collecting revenue and reaching otherwise excluded groups, such as the informal sector or rural populations. Negative features Overview These schemes are rarely financially sustainable, due to limited funds being inputted into the scheme (70% of CBHI schemes require public funding subsidisation (Erkman 2004). Usually all members are required to pay a contribution to the fund. As a result, the poorest people are unable to pay and therefore unable to access healthcare; This approach can lead to limited membership and therefore a small pool of funds, hence limited cross-subsidisation across rich and poor people, and healthy and sick people. It is difficult to transform community-level schemes into national systems and therefore it is not a route to achieve universal coverage. There is a lot of interest in this mechanism from low-income countries as CBHI is seen as an improvement on user fees and as providing some level of risk protection. But it still does not ensure that the most vulnerable can access appropriate and effective healthcare, at an affordable cost. As a result, it is difficult to scale up, and will therefore not lead to universal coverage. Cost recovery in Rwanda Cost recovery systems were reintroduced in Rwanda in Their negative impact on access and outcomes meant that the government introduced CBHIs 6, in an attempt to achieve universal coverage and protect vulnerable people. Today, these schemes are said to cover about 70% of the population. However, concerns for the remaining 30% of the population who are unable to pay the contribution and are not accessing healthcare, as well as concerns about the lack of financial sustainability of the system Private health insurance Private health insurance is insurance that individuals or their employers purchase to cover their healthcare expenses. Positive features Theoretically this approach enables the healthcare of the relatively affluent to be self-financed, freeing up public resources for those unable to purchase private health insurance. 6 Contrary to all other CBHIs, the scheme in Rwanda is compulsory. We have chosen this example however as it is the one that is most often cited as the example to follow. 11

12 It can mobilise additional resources for health infrastructure that benefits poor and rich people alike. It can encourage innovation and efficiency, which may catalyse the reform of the public sector, while increasing choice for the consumer. It is based on a pre-payment system, ie, people pay at various times throughout the year, unrelated to sickness, which avoids any type of cost being incurred when sickness occurs. Negative features Overview Private health insurance focuses on people in the formal sector and who can afford to pay the private insurance premiums. It creates a two-tier health system, where those with private health insurance can access better quality services. When subsidised by the state, it can prove to be very expensive for the government. Private health insurance, as the dominant source for financing, will not enable access to healthcare for poor people and those who are most vulnerable. and therefore other mechanisms which promote greater access need to be promoted. There may be scenarios where it plays a small complementary role to the financing of health services overall, where people with high income can choose to pay for it. Conclusion The section above summarises some of the main health financing mechanisms available in low-income countries and fragile environments. Overall, public financed systems are more desirable as they provide greater protection to the entire population and are more equitable. The important challenge for all stakeholders is what health financing mechanism(s) should be proposed to improve access to essential healthcare. In the long-term, the answer seems clear: tax-financed systems are the most equitable and efficient, if properly implemented. However, as this paper has pointed out, particularly in low-income countries and fragile environments, there are many short-term challenges to the implementation of these systems such as a weak administration systems and small formal sector. In the short term, the answer is more complex: CBHI, PHI or SHI all have serious limitations, but are more feasible than tax-based systems. The role of international donor aid as an additional source of funding also needs to be taken into account. International aid can help improve access, while at the same time building the mechanisms of the future that will allow domestic funding of the health system. Adopting a mixed approach in Ethiopia It is important to note that no low-income country has chosen a single health financing mechanism, but rather a combination of some, or all, of these mechanisms to improve access in the short and long run. Ethiopia, for example, is considering a number of health financing approaches to cover different groups of the population. The country is going through a number of healthcare financing reforms, moving away from its historic reliance on user fees to a combination of: 12

13 fee waivers and exemptions for targeted groups of the population Social health insurance for formal sector employees (including civil servants, public enterprise employees, private sector employees), with implementation to start in Community-based health insurance, designed as an insurance scheme for the wider, informal sector, currently being piloted in some areas. These approaches will need to be evaluated. 13

14 4. Planning your engagement on health financing This next section looks at some questions for your team to consider when deciding whether to engage, or continue to engage on health financing issues and the type of engagement that may be appropriate. It is split into two sections, policy and programmes. 4.1 Engaging in policy issues Phase 1: Establish the context and aims of engagement The objective of phase 1 is to stimulate discussion within the organisation/country team on health financing in order to: Understand the country or area context Establish where you are (through a situation and stakeholder analysis) in relation to where you want to get to (ie, by agreeing your organisation s end goal or ideal scenario) Review your team s current capacity. What are you aiming for? What is your organisation s policy on health financing (see section 2)? For example, Save the Children UK s aim is to achieve universal coverage of a basic package of quality services available free at the point of use. Merlin s aim is to see a health financing system in place that supports access to essential healthcare, especially for the most vulnerable. If this policy was implemented, what would you expect to see in terms of access to healthcare for your target population? Do a situation analysis As a team, establish what the current situation is in terms of health policy by answering the following questions: Who are the policy stakeholders in your area? (They may be the national or regional Ministry of Health (MoH) s policy, or a donor that is funding policy for a programme in your area.) What are their policies on health financing? Is the policy the same as your NGO s? And if not, how does your policy differ and what elements of the policy currently restrict access to healthcare? Once theoretical gaps have been identified between your ideal policy and your stakeholder s policy, you also need to identify gaps in implementation by asking Is the policy actually being implemented as originally intended? For example, if there is a user fees system in place with exemptions for the most vulnerable, are those exemptions implemented and functioning? Phase 2: Gathering evidence If you have the capacity within your team, or can increase capacity by working with other NGOs or by hiring additional staff, consider how to engage with your stakeholders the MoH or a donor that is funding work in your area. 14

15 One way to do this is to feedback on the implementation of their policy, using evidence from your programme s experience. The best way to achieve this is to support your understanding of the situation with practical evidence, through data collection. How to collect data and what data to collect? This guide describes an ideal scenario for data collection, but of course you will have to adapt it to what is possible in your context. The time and resources (both financial and human) that you have will determine how rigorous you can be in data collection. The evidence you collect could be primary data (ie, original evidence from your programme) and/or secondary data (from academic journals and policy reports by NGOs or the MoH). Make sure that your secondary data is not out of date. Start with a research question that is appropriate for your context. For example, if you are looking at the MoH s policy of user fees, your research question could be Are user fees a barrier to access essential health services, for pregnant women and children under 5? Once you have defined your research question, use a mix of quantitative and qualitative methods and data to find your answers. A quantitative approach Method: Develop a questionnaire that captures household data (revenue, wealth index, distance from health facility, barriers to access, etc). The group of people you ask could be from a randomly selected, representative of households, in one or more districts. Data type (examples): Utilisation rates and access information ideally by group such as: financial barriers for vulnerable groups of population geographical access to healthcare facilities broad information as well as specifically for antennal care and deliveries within health facilities, vaccinations. Quality of healthcare such as: number of health workers training available medical equipment drugs available surveys on quality of health delivery and client satisfaction, including knowledge, attitudes and practice (KAP) surveys. Macro data such as: population densities and vulnerable assessment maps top five causes of mortality and morbidity demographics of children under 1 (projecting the health need for this age group and then comparing it to actual utilisation rates) income and expenditure on health (including direct and indirect costs such as transport), what percentage of expenditure is spent on health and willingness to pay with wealth indexes. A qualitative approach Methods: Semi-structured interviews or focus group discussions with key groups or individuals. Qualitative information helps to bring alive the dry quantitative data 15

16 will obtain. Hearing the perspectives of participants and exploring the meaning they give to phenomena may deepen your understanding of an issue. Data type (examples) People s perception(s) of the quality of care People s reasons for not going to a health facility People s approaches to seeking care Whether informal payments are made and in which format How people decide to immunise or not their children, to seek or not care. For examples of similar research undertaken by Save the Children UK, see The Cost of Coping with Illness, available at With this collected data (primary programme data or secondary), you can start assessing against your research question, such as are user fees a barrier to access essential health services, for pregnant women and children under 5?. This assessment can form the basis of your engagement with the MoH or donor and of your advocacy work in general Phase 3: Advocacy In addition to feeding back on your programme s experience, it may be appropriate to advocate for policy changes to enable greater access to healthcare services. What do you want to change? If your analysis shows that changes or updates need to be made to the policy so that it promotes access, show your analysis to the district/provincial or national MoH or donor, whose policy you are seeking to influence. Give them technical advice on what would need to be changed to enable access and how to do it. As part of this technical advice, it may be helpful to highlight constraints to the changes you seek and, if possible, what you would advise in order to overcome these. For example, if there is a known constraint within the MoH, e.g., lack of financial resources, you could propose policy changes that improve access within the boundaries of that constraint. Finally, if your NGO has the capacity and skills, offer to pilot a specific health financing scheme that demonstrates the benefits of your advocacy proposal. If your analysis shows that the policy is not being implemented in practice, consider using your knowledge and the data from your programme, or other evidence you have collected, to demonstrate the problems that are currently occurring in practice. Feed back this information, along with recommendations to overcome these problems, to the MoH or donors. There may be times when both the policy needs to change and the existing policy is not being implemented. In such scenarios you could consider whether you seek to influence and change the overall policy and/or to highlight where the current policy is not being implemented. Consider the most appropriate approach for the short and long term. Agreeing your targets Once you have defined where you are and where you want to get to (phase 1), with evidence backing your reason to want to get there (phase 2) for example, you are in a 16

17 system where fees limit access to healthcare and you want to get to universal coverage of good-quality primary care you need to identify who may support your ambition (eg, civil society, other INGOs, donors, the government) and who may oppose it (eg, private forprofit providers, parts of the government, some donors). This can be done very quickly, by sketching out what you know or brainstorming with a few knowledgeable health stakeholders, or more thoroughly through a series of stakeholder analyses, sketching out who are your friends and opposition. This will enable you to understand who you need to convince, what approaches and strategies you will need to use and who you can build partnerships/coalitions with to add power to your message. Working together, with those who have the same or similar ambitions, has a number of benefits. Data, experiences and resources can be pooled. Advocating on a health financing issue with one collective voice gives you more authority. One of the advocacy tools available to you is the use of a public campaign. Based on your stakeholders analysis, you can assess whether a public campaign will help your advocacy objectives and ensure that pressure is put on those decision makers that are blocking the policy change you seek (be they national or international decision makers). In order to influence change, you also need to have a good relationship with key people within the MoH and/or donor(s) in order to offer technical advice. Fostering good relationships and developing trust is therefore key. Your advocacy plan Overall, the following list of key actions should be taken when developing an advocacy plan: 1 -Set goals and objectives. 2 - Map who can do what in your NGO and consider whether you need to increase capacity by employing extra staff or a consultant. 3 - Ensure, through phases 1 and 2, the necessary understanding of the policy environment. 4 - Identify targets and people to influence. 5 - Identify key messages and asks. 6 - Work with others through partnerships if helpful. 7 - Develop and implement action plan. For further info on how to develop an advocacy plan see Advocacy Matters: Helping Children change their world, available at: Merlin staff should consult Merlin s How To on Influencing (which can be accessed on Merlin s field CD or ask Head Office s Policy Team). 17

18 4.2 Designing and implementing a programme for the Ministry of Health or a donor When designing a programme for your country s MoH and/or a donor, you should consider whether the policy of your NGO (Merlin or Save the Children UK) on health financing aligns with the health financing policy of the MoH or donor that you have been asked to implement Identifying barriers Are there barriers that may hinder you being able to implement the health financing policy in practice? These could include, for example, that there are not enough health staff to provide healthcare to the population or that staff pay is insufficient, leading them to seek informal payments to increase their salaries. If there are potential barriers, raise your concerns with the people who asked you to implement the programme to see whether the barriers can be reduced or overcome, before the programme is implemented Baseline data What data can you collect to show the impact of the programme on the access and quality of healthcare? Do you also need to consider collecting data before the programme starts to ensure you can compare the impact of the programme with the baseline? What if there is a policy difference? If your NGO s policy does not align with the policy of the MoH or donor that you have been asked to implement, consider the following: From your situation analysis, you should know: The differences between the policy you have been asked to implement and your NGO s policy If there are any barriers to improved access to essential healthcare. If there are identifiable barriers, discuss these with the MoH or the donor to see whether there is any flexibility in the design of the programme. Could the differences/barriers be overcome by changes to the design in the programme on a permanent or (for piloting) temporary basis (if you have sufficient capacity to implement this)? You can use evidence of the impact of the proposed policy to support your case. If there is no flexibility, consider the implications for your NGO (eg, could you implement a policy not aligned with your own, but use data collected from the programme as your platform to advocate future change?) and for the population (eg, without this programme, would health services and therefore health status be better or worst for the population in the short and long run?). 18

19 5. Country case studies Liberia programme offices engaging on health financing at a national level In Liberia, no charges are in principle made for healthcare at primary, secondary and tertiary level (this is Liberia s current MoH s policy on health financing). The MoH, in the last few years, has been reconsidering its health financing policy position and questioning whether it is financially sustainable to continue with free healthcare in the future. To inform this review, the MoH set up a Health Financing Task Force, which Merlin is the INGO representative on (Merlin was nominated by the other INGOs, due to its long presence in Liberia and because of its experience as the largest NGO-provider of health services within Liberia). Merlin was specifically asked by the MoH to provide technical expertise in evaluating Community Based Health Insurance scheme (CBHI) as a health financing option for the country. The Merlin Country Office recruited an external consultant to their team to add capacity and expertise. Since then, Merlin has been giving technical advice to the Task Force drawing heavily on data and from Merlin s programme experiences within Liberia. As part of the work for the Task Force, Merlin was also involved in the validation of costing for primary healthcare and has been recently been requested to support the development of a basic package for hospital care. Merlin also plan to support the MoH by making relevant links to external resources such as the DFID Centre for Progressive Health Financing, which provides technical support on health financing. Recommendations for other country programmes: If you do not have capacity or the appropriate expertise within your team, consider employing, on a short-term basis, a member of staff or consultant to help. In your area, assess access to healthcare at primary, secondary and tertiary levels, as you may advocate on different issues at different levels. Where possible, use data and other evidence from your country programme to add legitimacy and authority to your work. This will help move the debate from the theoretical to the reality of the programmes in your area/country. Despite the national political commitment to the removal of user fees, the policy is not yet fully implemented because of a lack of financial resources (this gap could be filled, in part, from additional international aid from donors). The main donors in the country remain sceptical and have not come forth with additional funds, thereby preventing the implementation of the policy at present and the government is therefore considering other short term solutions. 19

20 Sierra Leone systematic engagement, with partners, at national and district level Until 27 April 2010, user fees were charged for all population groups in Sierra Leone. One of Save the Children UK s main policy focuses is the removal of user fees for healthcare. Save the Children UK therefore started by collecting quantitative and qualitative evidence on the barriers user fees create. With this evidence, we started a policy dialogue. In 2008, Save the Children UK partnered with Médecins Sans Frontières (MSF). MSF has widely documented the impact of user fees on access to healthcare and it was felt that to work as a coalition would bring added power to our message. Both organisations therefore set up a roundtable discussion with key policy-makers (MoH, donors and health implementing partners) to attempt to put the removal of user fees on the political and technical agendas. Health financing experts were invited to the discussions to ensure that added credibility was given to the evidence presented. This was followed up by regular meetings with key MoH policy-makers and donors health experts. Further advocacy work led to the announcement in September 2009, by the country s president, that user fees would be removed from the 27 April After the announcement, Save the Children UK worked closely with the government at national and district levels and with other health partners to plan for user fees removal. Our involvement not only focused on communication of the new policy change, but also technical advice, for example, on developing a strategy to finance the new health policy. The removal of user fees will be funded through an increased allocation of government resources to health, as well as an increased aid allocation to the health sector. The government is considering social health insurance and tax-financed systems as alternative medium- to long-term financing approaches. In March 2010, health staff went on strike, asking for an increase in salary before fees were removed, thereby threatening to block the whole process. An agreement to increase their base salary six-fold has finally resolved this, but it may lead to discontent from other public workers. In contrast with Liberia, Sierra Leone benefits from international support (particularly from the UK government), which means that in the short-term Sierra Leone is able to allocate additional resources (both domestic and international) to the removal of user fees while planning for medium to long-term alternatives. Recommendations for other country programmes: If you suspect that user fees are a barrier, collect data through a mix of quantitative and qualitative methods to help assess whether they are preventing healthcare access. Save the Children UK has a lot of experience on this. Contact your health policy adviser in London for further details. 20

21 Once you have the evidence, go through the questions outlined above on how to develop an advocacy plan. This will mean that your actions are focused and make sense within a broader push towards policy change. It will also mean that you will have identified potential partners (other NGOs, government, etc). Health staff/human resources are a key stakeholder to help policy changes to work. Make sure when you engage on health financing that you gather their views, recommend that they are always included in discussions, keep them aware of progress and consult them throughout. If you do not have the in-house expertise, recruit a consultant to help you define your research approach. Evidence collection is crucial to any advocacy plan if you hope to change policy. Democratic Republic of Congo (DRC) piloting different financing mechanisms at a provincial level In the DRC, Merlin engages on health financing at a provincial level, primarily though piloting different health financing mechanisms in a number of provinces, on behalf of donors. Merlin then feeds back, to the MoH, the impact of these different policies on access to good-quality health services for vulnerable populations. The country s MoH policy is cost recovery, through fees for service. Some donors however have provided funding for free or targeted health services, implemented by Merlin and hence out of line with the national policy. Merlin therefore has negotiated with the provincial MoHs to allow piloting of programmes that go against national policy to take place. Data from the programmes on the impact of fees on different socioeconomic groups capacity and willingness to pay is therefore key when feeding back to the MOH. Merlin is currently piloting programmes in two different provinces: In North Kivu Province, Merlin is implementing a financial scheme with MoH and donors to ensure free healthcare at the point of delivery for all clients of health facilities to avoid positive discrimination for internally displaced people (IDPs) and the host population. IDPs are the targeted vulnerable group for donors and Merlin; In Maniema Province, Merlin will be implementing a financial scheme with the provincial MoH and donors to ensure targeted free healthcare at point of delivery for pregnant women, children under five and registered indigents. Merlin captures data from its programmes and uses it in a number of ways: To study the impact of economic barriers in utilisation rates of health facilities and its relation with the quality of health service delivery, feeding back to the provincial MoH and/or donors. T o advocate with the provincial MoH and Donors to implement a safety net financial system for vulnerable groups (universal health insurance, mutuelles de 21

22 santé or community saving schemes). To calculate a minimum cost-sharing fee and its modalities (fees-for-services, feesfor-drugs, etc) because the MoH health policy still considers cost-sharing by users as a way of financing the health system. Merlin does not always work alone on these issues, rather it ensures the right mix of skills by working in partnership with others. For example, in Maniema, Merlin is engaging with the International Rescue Committee and Oxford Policy Management Group to start monitoring and to document in a systematic fashion targeted free healthcare in that province. Burundi collecting evidence from country programmes Save the Children UK was operational in Burundi and decided to collect evidence on the impact of user fees in the country. We evaluated the impact of the financial cost on healthseeking behaviour and households behaviour and their ability to cope with the burden of healthcare costs. We also evaluated the sustainability of community financing and attempted to identify alternative options. Data was collected at the community level through a household survey, focus-group discussions, a health facility survey and key informant interviews. We collected evidence in three districts: Gitega, Mwaro and Muramvya. We found that user fees were the main barrier to accessing healthcare in the country and that poorer households were overall likely to pay more as a proportion of their income than rich ones. We used this evidence to advocate for policy change though meetings with key decision makers. This advocacy, coupled with other organisations efforts such as Human Rights Watch and MSF, led to the removal of user fees for pregnant women and under fives in The decision to remove fees was announced by the President in the main Bujumbura stadium, without prior consultation with donors and national ministries. It is thanks to a combination of debt relief and support from international partners such as ECHO and DFID that the removal policy was implemented and worked immediately. Recommendations to other country programmes: Use a mix of qualitative and quantitative methods to collect evidence. Work with partners to achieve your advocacy objectives. Do not get disheartened by a lack of planning at the national level. For more information on Save the Children UK s policy work in Burundi go to Tanzania collecting evidence from country programmes 22

23 In the 1990s, the Tanzanian government introduced user fees for healthcare. Save the Children UK was working in Lindi rural District and decided to undertake research looking at the impact of user fees on the access to healthcare. We used a household survey, household economy analysis, focus group discussions, in-depth interviews of households affected by illness and key informant interviews. We found that: cash availability across all households was low; there was a high burden of both chronic and acute ill health; a substantial proportion of the population failed to seek treatment; and poorer households were likely to pay more of their income than richer ones. We published our results and used it for policy dialogue in Tanzania and at the international level with the main donors. For more information on Save the Children UK s policy work in Tanzania go to 23

24 6. Conclusion This guide has given you an overview of the various mechanisms that exist for financing a health system, and a better understanding of their strengths and weaknesses for helping improve access to essential health care in your country. Remember that no country uses a single approach, and that there will always be a mix of mechanisms in place. This guide has also given you some tips about how to engage at the policy and programme level on health financing, in your country; setting out some key questions to consider when deciding whether or not engaging makes sense to your programme and highlighting some country examples where different levels of engagement have already occurred. We hope you feel more empowered to engage at the policy level with these debates. For any further support, don t hesitate to contact your relevant head office or country level staff. 24

25 7. Reading on various health financing mechanisms 7.1 On all financing mechanisms: McIntyre D, Gilson L, Mutyambizi V (2005) Promoting equitable healthcare financing in the African context: current challenges and future prospects, Equinet Discussion Paper Number 27, October 2005, available on Schieber et al ( ) Financing health systems in the 21st century, chapter 12, Disease Control Priority project, The World Bank, available on Mills A (2007), Strategies to achieve universal coverage: are there lessons from middle income countries?, World Health Organisation, available on erage_2007_en.pdf Scheiber and Maeda (1997) A curmudgeon s guide to financing healthcare in developing countries, in G. Scheiber (ed.) Innovations in Health Care financing, Washington DC, World Bank 7.2 On taxation: Di john J (2006), The Political Economy of Taxation and Tax Reform in Developing Countries, Research Paper No. 2006/74, UNU World Institute for Development Economics Research (UNU-WIDER), available on Tuan Minh Le, Blanca Moreno-Dodson andjeep ojchaichaninthorn(2008), Expanding Taxable Capacity and Reaching Revenue Potential: Cross-Country Analysis, Policy Research Working Paper 4559, World Bank, available on On social health insurance specifically: Carrin (2002) Social health insurance in developing countries: a continuing challenge, International Social Security Review, Vol 55 (2): 57-69, available on Arhin-Tenkorang D (2001), Health Insurance for the Informal Sector in Africa - Design Features, Risk Protection, and Resource Mobilization, Commission on macroeconomics and Health, HNP Discussion Paper, available on N/Resources/ /Arhin-HealthInsurance-whole.pdf 25