New approaches needed for a less fragmented health financing system

In many countries, the health financing system involves a disjointed mix of health financing mechanisms. A paradigm shift is needed. And stakeholders working on universal health coverage (UHC) must acquire new technical skills to effectively coordinate this fragmented landscape. In this blog, I will explore ways forwards, including the role that the P4H Network can play in this area as a facilitator of dialogue across sectors.

Photo: Knowledge-sharing workshop on the use of performance-based financing for UHC, Abidjan, 10-11 February 2022

Fragmented health financing system: a fundamental problem for UHC

As a health financing specialist, I observe that countries often implement a mix of health financing mechanisms to increase financial access to health care (budget financing, mutual health insurance, compulsory insurance, free health care for certain groups, equity funds for people living in poverty, performance-based financing (PBF), etc.). But this combination of mechanisms is rarely conceived as a whole. More often than not, it is merely the historical accumulation of uncoordinated decisions.

This mix is potentially a source of inefficiency and inequity, as some groups may have more safeguards against financial risk, giving them an advantage in accessing public resources, to the detriment of others. The problem is not new. In 2014, a study I helped conduct mapped out the financing mechanisms in 12 francophone African countries and highlighted the problem of highly fragmented health financing systems. A lack of coordination and strong reliance on external aid that jeopardize efficiency, equity and sustainability characterize these systems. The study concluded that UHC is unlikely to be built on such a disjointed mix of health financing mechanisms. Moreover, this patchwork approach could impede improving health financing systems and ensuring social health protection.

Thus, achieving progress towards UHC is more a matter of reformulating or combining already established mechanisms to make them more coherent and efficient. To borrow Bruno Meessen's colourful phrase, building UHC is “the work of urban planners, not architects”. We need to change the mindset in ministry offices, agencies, and in the research sector. Rather than focusing on the design, implementation and performance of a specific mechanism, we should focus on building the system as a whole.

The role and added value of P4H country focal persons

For more than a decade, the P4H Network, with whom I have been working for the past few months, has been striving to create and use spaces in various countries for collaboration and dialogue among institutions and stakeholders working on social health protection and health financing .The P4H Network provides expertise and support for strengthening countries' social health protection and health financing policies to better equip countries move towards UHC.

To achieve these goals, one assistance best practice that the P4H Network follows is to support the in-country establishment of focal persons (18 worldwide as of 1 July 2022) with a specific mandate and technical and institutional legitimacy. Also, P4H country focal persons integrate themselves into forums for technical discussions among various national stakeholders, representatives of different sectors, and organisations supporting social health protection and health financing. These practices bring together stakeholders working on social health protection and health financing and facilitate the integration of in-country policy and technical discussions. At all times, P4H country focal persons actively serves as an honest broker and facilitator.

Once in 'their' country, P4H country focal persons continually strive to ensure that potential change agents promote collaboration, align their various perspectives in a more synergistic way, establish connections and regularly discuss collaborative ways to improve health financing, social health protection, public funding for health and other related areas of intervention.

Leading this collaborative effort means identifying intermediate steps, such as regular and systematic information sharing among relevant stakeholders in-country (e.g., through co-management tools, shared calendars, common virtual libraries, and experience-sharing workshops). All of this is possible given the mandate of the P4H Network, which first seeks to identify information gaps between its members and national or international partners, then acts as a broker to facilitate ongoing communication among them.

This process is important because in some cases, certain stakeholders promoting a specific financing mechanism may be inclined to leverage their resources to influence the debate, or to disguise their particular approach as a comprehensive, one-size-fits-all solution. They tend to challenge competing assumptions and available evidence, rather than acknowledge the coexistence of competing points of view. However, more communication, negotiation, and a mix of proposals that reflect different perspectives could make for a more supportive environment and more coherent system.

Côte d'Ivoire's February 2022 performance-based financing workshop: an opportunity to build bridges among actors

An opportunity recently arose in Côte d'Ivoire. In collaboration with the Global Financing Facility for Women, Children and Adolescents (GFF), the World Bank and WHO, and with the support of the Joint Learning Network (JLN), the P4H Network supported a knowledge sharing workshop on the use of PBF for advancing UHC.

Held in Abidjan, the workshop drew 64 participants, including technical advisors, directors and research analysts from the Prime Minister's Office, the Ministry of Planning and Development, the Ministry of Budget, Economy and Finance, the Ministry of Health and Public Hygiene - Universal Health Coverage, and the Ministry of Labour and Social Protection, along with technical and financial partners, oversight and audit agencies, the PBF programme’s independent external counter-verification unit, and the World Bank’s Health Project Coordination Unit.

This knowledge exchange enabled health financing practitioners in Côte d'Ivoire to learn about various experiences that could help guide a possible reconfiguration of PBF so that this approach could be better integrated into the broader goals of  providing UHC and strengthening the health system in particular and the public sector more generally.

In Côte d'Ivoire, a number of health reforms are being implemented in parallel. For example, there is overlap between various aspects of free health care, the scope of UHC and PBF procurement indicators. This overlap is observed despite the National Platform for Health Financing Coordination, a framework for dialogue among bodies managing these reforms since 2019.

This workshop was a further example of the value, relevance and timeliness of the P4H Network.

Value, because the P4H Network brought technical and other resources to the event and served as a neutral broker with regard to health financing issues.

Relevant, because of the role P4H plays, specifically in supporting collaboration between WHO and the World Bank, which is central to their common agenda in support of UHC.

Timely, because as the P4H country focal person, I am recognised both for my expertise on issues under debate and for my role as facilitator. Facilitation is critical and instrumental to events like the PBF workshop having the air of neutrality and being a success. In my dual capacity, I participated in preparatory meetings and helped draft the terms of reference and an agenda for the workshop. I also gave presentations and coordinated some of the group work.

Ways forwards

Like many other countries in francophone Africa, Côte d'Ivoire has undertaken an ambitious UHC programme. This programme will build on various health financing mechanisms that are already in place.  Establishing coherence among them is one of the biggest challenges to advance UHC. This is a critical issue for health financing.

The success of UHC therefore requires a paradigm shift and a new way of thinking about health financing. The key words that should guide this new mindset are convergence, alignment, dialogue and being proactive. We need to understand how to mobilise the many stakeholders without discounting the diversity of their intervention approaches (free health care, PBF, mutual insurance, etc.), while also taking into account the evidence and the diverse schools of thought, principled positions, and belief or value systems. This shift also applies to development agencies, which are being asked to adopt more synergistic practices and which need to review their individual funding and resource allocation strategies that are often too targeted and top-down.

For over 20 years, WHO has been "focusing on the whole", rather than on individual mechanisms, and even included this focus in its recent health financing progress matrix. In the first stage of the matrix, analysts determine the extent of fragmentation within the health financing system through a descriptive landscape of the major health coverage schemes and programmes in the country.

This systems approach will hopefully also inspire the evaluation community. By focusing on a specific instrument, rigorous assessments have sometimes fostered the illusion that the ultimate solution lies in a single mechanism. At times, they have also paid too little attention to the interactions between one funding mechanism and other existing mechanisms (or the interdependence of funding policies with other "components" of the health system).

This "focus on the whole" encourages further reflection on these issues of how health financing mechanisms should be linked and complementary and how this mix needs to be managed actively but also collaboratively, with an emphasis on efficiency and state leadership.

This mind-set also requires capacity building for experts and other stakeholders to better guide their strategic choices concerning future needs and the functionalities required to achieve UHC; and to better prepare them to make the transition to a broader and more inclusive expertise.

Today, the whole is less than the sum of its parts when it comes to health financing. The time has come to change this situation - and this can only be done by abandoning the piecemeal approach that has prevailed over the last two decades.

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