Billy Stewart

1
Health system development for equity a
bilaterals perspective

• Billy Stewart
• Health Adviser, Global Health Partnerships Team
• December 2005

1 Palace Street, London SW1E 5HE Abercrombie
House, Eaglesham Road, East Kilbride, Glasgow G75
8EA
2
About this presentation

• Objective to move closer to a coherent view
  which
• better links the scaling up of TB services with
  the broader scaling up agenda for health, and
• questions how we can apply an equity lens at all
  levels
• Outline
• Discourse on equity
• Scaling up in health DFID analysis
• Challenges to scaling up for health
• User fees
• Social transfers
• Global initiatives
• Role of donors better aid
• Conclusions

3
Why the concern with health equity? (1)

• A matter of
• Economic growth - equity in human capacities
  through health ( education and social
  protection) is key strategy to level the playing
  field for people to lead productive, fulfilling
  lives WDR 2006 CfA 2005
• Development and poverty reduction - equity at
  core of health systems is prerequisite to
  achieving MDGs WB 2004, WHO 2005
• Social justice and human rights - risk of scaling
  up not delivering benefits to the poor/poorest
  and socially excluded WB 2004

4
Why the concern with health equity? (2)

• Health system as core social institution can
  increase inequity and social exclusion, or
  protect citizens from poverty and discrimination
  UNMP 2005
• Recognise need to make health systems more
  inclusive and equitable AND to address underlying
  causes of health inequalities (eg. Income,
  nutrition, education) WHO CoSDH
• Increasing international commitment to tackling
  inequities
• Scaling up resources reduces trade-offs between
  equity and efficiency new choices

5
Scaling up in Health 1 G8 commitments at
Gleneagles

• G8 responded to Commission for Africa
  recommendations by agreeing
• Comprehensive package of support the big push
  on peace and security, governance, health,
  education.
• Additional 50bn globally and 25bn for Africa by
  2010
• Debt relief worth up to 55bn for up to 38 of the
  poorest countries, as well as 17bn for Nigeria,
• Developing countries have the right to plan,
  sequence and implement their own economic
  reforms.
• Africa Partnership Forum should monitor
  implementation

1 Palace Street, London SW1E 5HE Abercrombie
House, Eaglesham Road, East Kilbride, Glasgow G75
8EA
6
Scaling up in health 2 DFID Paper Plan of
Action

• To turn commitment to action will require
• Increase in overall aid for health in low income
  countries of 20 billion by 2010
• Support to governments to develop ambitious plans
  once financing commitments are clear
• Donors to make progress in implementing the Paris
  commitments on aid effectiveness and
  recommendations of the GTT on AIDS
• Donors to commit to developing and piloting
  mechanisms to increase the predictability of
  development assistance for health
• Partner countries to meet their commitments to
  increase funding to the social sectors

7
Challengesall have an equity dimension

• Balancing targeted approaches and health system
  strengthening
• Increases in resources that are spent more
  effectively and equitably
• Responding to the health staffing crisis
• Harnessing the contribution of non-state service
  providers
• Increasing demand and accountability
• Strengthening governance
• Investing in better health in fragile states
• Building effective health information systems
• Research into the health problems of low income
  countries

8
Challenges User fees - 1

• Charging poor people fees for service can be a
  significant barrier to access basic health care
• Removal of user fees does not equate to universal
  free services for all (G8 and HMT commitment)
• Removal of official user fees has less impact
  where
• Many other cost barriers faced by poor people
• Many other social-cultural, geographical barriers
• Dominant private sector service provision
• Symptom of under-investment in primary healthcare
• Also need investment in service expansion and
  quality

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Challenges User fees 2

• DFID policy line (2005) Yes, remove user feesbut
  its not a magic bullet
• Support removal of official user fees for basic
  health care
• Help identify alternative sources of finance
• Encourage removal of other fees and charges
• Part of broad-based efforts to fund and deliver
  quality, equitable healthcare for all (eg. Uganda)

10
Challenges Cash transfers - 1

• Non-contributory, regular and predictable cash
  grants delivered direct to households or
  individuals
• Demand-side financing and social protection
• Multiple objectives reduce income poverty,
  hunger food security, child labour improve
  human development can also stimulate local
  markets and growth OVC care package
• Can also provide sense of entitlement to claim
  citizens rights to access services

11
Challenges Cash transfers - 2

• Cash transfers can improve human development
  (CfA,WB)
• Equitable access to services tackle demand side
  barriers beyond user fees - indirect and
  opportunity costs, gender discrimination
• Tackle factors underlying health inequalities
  malnutrition, income poverty
• Target resources to poorest and socially excluded
• Prevent inter-generational transmission of
  poverty
• Also need investment in health and education
  sectors to respond to scaled up demand and to
  improve quality

12
Conditional vs. no strings attached

• Evidence of Latin American conditional cash
  transfers marked increases in utilisation of
  primary health care and school attendance and
  performance also in nutrition and health
  outcomes
• Well-targeted to the poorest
• Unconditional cash transfers more flexible,
  spent on household priorities Namibia and South
  African pensions
• Less evidence in low income countries pilots in
  Kenya (OVC) Kalomo district, Zambia
• Need to monitor and evaluate pilots as they move
  into national safety nets compare conditional
  vs. unconditional
• Politics

13
Challenges Global Health partnerships - 1

• Opportunities
• Increasing within context of growing assistance
  in health
• Targeted at the poorest countries
• Support cost-effective interventions
• Technical/advocacy partnerships promote
  equitable approaches
• Risks
• Transaction costs - multiple coordination
  structures
• Impact on domestic resource allocation
• Introduction of high value commodities
  countries running to keep up, or
• Entrenching lower levels of spending
• Impact on health systems role of community
  health workers

14
Challenges Global health partnerships - 2

• Alignment
• Simplification of coordinating mechanisms
• Coordinated health workforce policy framework

After Sigrun Mogedal
15
Donor financing 1 DFID paper making aid more
effective

• Channel scaled up aid through range of
  instruments where possible use flexible
  programmatic instruments (PRBS, sector budget
  support)
• Better ownership and alignment to national
  priorities, improved efficiency in public
  expenditure management, reduced transaction costs
  all should impact on equity
• Marginal costs of expanding are lower than for
  project finance
• Broad based approach to tackling MDGs (e.g.
  capacity in education to train more health
  workers)
• Additional public spending needed will be largely
  recurrent costs needs longer term predictable
  finance

16
Donor financing 2 SWAps and PRBS Opportunities
for equity (the theory)

• SWAps based on open participatory planning allow
  for incorporation of health needs identified by
  NGOs and civil society
• SWAps Resource allocation across sector
  according to national needs and priorities, not
  on a project basis
• Improved diagnosis of barriers to service
  utilisation
• PRBS the aid instrument most likely to support
  a relationship between donor and developing
  country partners which will help to build the
  accountability and capacity of the state (DFID)

17
Donor financing 3 SWAps and PRBS Risks

• Published evidence indicates limited
  participation of civil society (Foster, 2000)
• Little evidence that they help to resolve
  politically sensitive problems
• Risks of disrupted services during transition
  (Foster, 2000 though rpeorted as largely
  anecdotal)
• Risks that health sector will not receive fair
  share of funds under PRBS - education received
  greater priority for funds under debt relief
  programmes (Gilson, 2005)
• PRBS could it undermine the role of the Health
  Ministry by making Ministries of Finance more
  responsive to donors (Gilson, 2005)
• PRBS is it actually more predictable? (DFID
  PRBS paper)

18
Donor financing 3 SWAps and PRBS Way forward

• Health sector not marginalised where country
  aligned policies and plans for pro-poor service
  delivery in line with PRSp (Gilson, 2005)
• Also need specific targets for health care
  financing and delivery and monitoring of progress
  and outcome indicators. Role of qualitative data
• Malawi new relationship between NTP staff and
  District Health Officers to ensure quality TB
  services, increased case notification, and
  simplified diagnostic pathways
• Establishment of Equity and Access sub group in
  Malawi opportunity for lesson learning
• Link to wider poverty monitoring initiatives
• Analysis of existing data
• Review district allocation formulae
• National health accounts
• Review of accountability framework

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Conclusion Making the links

• On the TB programme side
• At country level For some time experience of
  integration of TB programmes but the challenges
  of new programmatic tools argue for attention to
  lesson learning both on service delivery and on
  equity
• Improve alignment and complementarity of global
  initiatives
• At global level Continue to mainstream equity
  within new Stop TB strategy TB and poverty
  network
• Provision of TA within overall human resource
  frameworks
• On the health and development side
• Poverty monitoring and analysis of barriers to
  access Malawi experience
• Monitoring and evaluation of outcomes inc TB
• Consideration of disease control services within
  sector reviews (include TB experts?)
• Broad based approaches to reaching MDG goals
  e.g. social transfers
• Understanding of resource needs for TB, linkage
  to health systems, fed into planning

1 Palace Street, London SW1E 5HE Abercrombie
House, Eaglesham Road, East Kilbride, Glasgow G75
8EA