On 13 and 14 October, health sector Reform stakeholders got together to receive an update on the Health Sector Reform programme of the MOH and discuss findings of assessments on two key proposed reforms: Health Fund (earmarking of general revenue for health) and National Health Insurance. World Bank supported the Health Fund assessment, GIZ the NHI assessment. The World Bank assessment concluded that Malawi has a very limited number of Options for earmarking General Revenue. The most promising being the reallocation of revenues from two fuel levies and a tax on motor vehicle insurance. Other proposals were not regarded as feasible due to high potential of replacement of legally traded goods by contraband (e.g. alcohol and cigarettes) or already high tax burden (e.g. extractive industries, airtime). The assessment was well received and MOH is planning to take this initiative further with MOF. Independent of this, in November industry has started speaking out against fuel levies as massive power supply problems and market-based increases in fuel prices make business increasingly difficult. The NHI Report by Oxford Policy Management assessed the following four reform Options: (1)Reform within the given institutional set-up; (2) Universal mandatory NHI for the Essential Health Package; (3) Universal mandatory NHI for tertiary care services; and (4) Purchasing Agency. It concluded that NHI would rely on the introduction of “service access fees” as an incentive to enrol and could therefore not be recommended due to the negative effects on equity of access to care. Malawi does not have the capacity to identify either informal sector households with a capacity to pay, nor a sufficiently well-developed country-wide mechanism to identify the poor. In view of expected efficicency gains from a purchaser-provider split, it recommended establishing a Purchasing Agency. Discussions on the NHI proposal were attended by stakeholders from the public and private health sector, the public finance sector, civil society, industry and the Health Committee of the National Assembly. Discussions were inconclusive on which reform model to pick as stakeholders appreciated aspects of different reforms. MOH tasked OPM with further analysis, incl. enabling the MOH itself to assess variations of NHI such as limiting mandatory membership to the formal sector, focusing on urban areas identification of non-poor informal sector households. A stakeholder mapping conducted alongside the Forum indicated most support to reforms within the current institutional setting, whereas NHI faced more opposition than other Options, especially in the public health sector (but also significant support in other groups). Parliamentarians expect MOH to provide guidance in early 2017 at the latest in order to commence a favoured reform option in the first half of the legislative period. Further analysis therefore needs to be concluded by end 2016 and dialogue with the highly interested law-makers continued. P4H Partners and MOH have been invited for a technical discussion on the next draft of the NHI assessment on 23 Nov. Presentations on the Health Fund and NHI assessments are found below, as is the NHI assessment Phase 2 report. Forum documentation and stakeholder mapping report will be made available soon. Update by: Kai Straehler-Pohl (GIZ)
KEY MEASSAGES:
Health Fund: Additional finances for health could be mobilized from domestic sources by
–Replacing the existing storage levy with a medical levy
–Allocating a share of the existing rural electrification (MAREP) levy to health
–Imposing a health tax on third party and comprehensive motor vehicle insurance cover
Respective World Bank presentation: Establishment of a Health Fund in Malawi_Preliminary Results
National Health Insurance:
– Opportunities to generate revenue from NHI premiums from non-poor households in the informal sector are limited
– Risks to unintentionally exclude poor households from access to health care are large
– Opportunities to gain efficiencies from paying for outputs instead of inputs if coupled with more localized management
– Purchaser-provider split maximizes opportunities but has risks through increased complexity of institutional relations
– Opportunities for additional general revenue in mid-term:
— Health Fund (fuel levies and 3rd party motor vehicles)
— Broadening of tax base to informal sector businesses
– Health system modeling shows wide financing gap will remain
Respective GIZ/OPM presentation: P4H_MalawiNHI_Phase1_131016_final-v2
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Other presentations given during the Forum:
MoH: Overview of Malawi Health Reforms and Progress To-date: HSR Overview at Capital Hotel 13 October 2016 CHAM: The PPP with CHAM: PPP Presentation- CHAM Summary presentation of D1 technical inputs (by GIZ): Health Sector Reforms – Focus National Health Insurance : NHI_RecapPresentation_KaiGIZ
