Institutional issues in targeted health interventions Hilary Standing Institute of Development Studies, UK

Key findings and questions  Importance of interventions that target the non-health costs of improving access for the very poor  Pivotal role of NGOs in providing institutional capacity often lacking in the public sector  Importance of attention to the supply side  Challenges in scaling up

Meeting the broader needs of the very poor Seem to work best when part of broader measures to address context of very poor people’s lives:  Broader measures against social and economic vulnerabilities  Transport and lost income - often a larger burden than fees for curative services and medicines.  Social obstacles, such as stigma, shame and lack of voice  Making health care accessible to the poorest requires institutional mechanisms which can minimise these costs and obstacles

Institutional role of non-state actors Do targeted programmes work best where there is reasonable state infrastructure, e.g. in MICs?  In LICs, importance of institutional actors and programmes that can “fill the gap” such as established poverty reduction programmes, large NGO capacity  Experience of beneficiary identification and targeting

Supply side challenges  Demand side social sector interventions generally more successful at increasing coverage than increasing quality  Programmes often introduced in settings where service quality is low, need for reform to supply side services especially initiatives are introduced in a monopoly- provider situation  Issue of incentives to create more responsive services

Governance challenges Schemes often over-administered but under- governed  Capable monitoring and governance bodies needed at both national and local level, to play informed and empowered advocacy/watch-dog role  Development of competent third-party purchasing organisations where beneficiaries are at informational disadvantages in evaluating which service they require/where best to access it  Quality-assurance standards agencies that can certify providers able to supply services to certain standards

Scaling-up challenges Targeted programmes often small-scale, generously funded, not sustainable  Programmes for reaching the poorest often rely on local knowledge, harder to transpose to large scale  Risks of elite capture of decentralised resource flows where allocation to localities is decided centrally, but dispersal is determined locally  Benefits of more simple rules, using existing infrastructure and experience