Health Systems 20/20 Caribbean: Partnerships for Health Financing Reforms in the OECS 1 Laurel Hatt, MPH, PhD Health Systems 20/20 Caribbean Project Abt Associates Inc. October 11, 2012

Leveraging USG resources for health systems strengthening U.S.-Caribbean PEPFAR Regional Partnership Framework aims to: Support greater HIV program financial sustainability Strengthen and expand public/private partnerships PEPFAR II emphasizes health systems strengthening to improve financial sustainability Emergence of HIV as chronic disease mandates sustained, integrated response Requires strong overall health system, including sustainable financing 2

USG Commitment at the 2011 OECS Health Ministers Meeting Shared results from 6 OECS health systems and private sector assessments Reviewed health systems’ strengths and weaknesses Prioritized areas needing attention Identified opportunities for technical assistance PEPFAR promised to provide support in the areas of NHA, public/private partnerships, and health economics related studies 3

Key recommendations from 2011 assessments Conduct costing studies to understand the true cost of public sector service provision, including HIV services Conduct NHA estimations, and build regional capacity to routinely produce NHA data Could UWI serve as regional hub? Conduct household health expenditure surveys Measure out-of-pocket expenditures, quantify use of private health sector Strengthen capacity for evidence-based planning Engage with the private sector to collect better data, contract for specialized services, improve dual practice regulations 4

Accomplishments in costing studies conducted Saint Lucia Antigua and Barbuda 2 NHA estimations initiated St. Kitts and Nevis Dominica National Consultation for Health supported Grenada Private health sector “mapping” exercises conducted Antigua, St. Kitts and Nevis, St. Vincent, Dominica 5

2012: Key messages National Health Accounts are critical to inform health financing reforms -- and NHA is feasible in the OECS Need for data on where health dollars are going Need for evidence-based planning: How can you “spend better”? USAID’s approach aims to build capacity of countries and regional institutions to inform health financing reforms and fill data gaps USAID/Abt/UWI partnership will continue to provide technical assistance on health financing reforms over the coming year 6

Activities going forward NHA Complete NHA in St. Kitts and Nevis Complete NHA in Dominica Initiate NHA St. Vincent and the Grenadines Costing studies St. Lucia Antigua and Barbuda National health insurance reforms Support process of NHI development in Grenada 7

Focus on NHA OECS countries do not routinely collect NHA data No out-of-pocket expenditure data No data from private sector providers or private health insurance Health spending information is urgently needed to: Understand current health care use and spending patterns for evidence-based planning Prepare for openings of new health facilities Design national health insurance schemes Leverage the resources of the private sector 8

National Health Accounts (NHA) Internationally accepted and tested (100+ countries) Initially sponsored largely by USAID Now: WHO, WB, BMGF, BTC, GTZ, EU, Sida etc., Tracks spending on health care including public, private and donor contributions Intended on a regular basis; INSTITUTIONALIZED Application to priority areas: SUBACCOUNTS. HIV/AIDS subaccounts Malaria subaccounts RH Subaccounts CH Subaccounts Conducted as part of general NHA exercise

NHA is not just a ‘study’… It is a PROCESS that works to establish resource tracking as a ROUTINE function of policy and planning NHA = a ‘vital statistic’ of sorts NHA is challenging: Requires information from many sources Necessitates participation, understanding, and ownership by all stakeholders: (including public, private, and donor) Requires trained team members from local institutions Should not be done by ‘external consultants’ Policy purpose must be clear from beginning Findings need to be analyzed and presented to inform policy needs --- otherwise will NHA report will collect dust on shelves. Works to address ‘information system’ needs to track expenditures

Single most important purpose of NHA is to contribute to health policy Contribute to the health policy process Can lead to better informed health policy decisions and avoid potentially adverse policy choices Answers key policy questions, such as Are we achieving the Abuja targets for government spending on health? What is the burden of financing on households? How much of funds are off-budget? What is the dependency for financing on donors? Who has programmatic control over resource allocation to providers? Are funds being spent in accordance with national strategic plans? What is the progress of contracting with the private sector? Intended for all health stakeholders: Government, Donor, civil society etc.

How has NHA impacted policy? Increased government investment in health Elevated the status of MDG priority areas Informed resource allocation decisions Held stakeholders accountable Informed civil society advocacy efforts Fostered need for greater coordination Monitored progress towards spending goals Exposed corruption and weaknesses in transparency

What is NHA? A methodology that systematically captures and compiles all health expenditures in a health system Whose money? Who’s managing it? Who’s providing care? What services are consumed?

NHA tracks every health dollar from the original source through the financing agent, to the provider, and finally to the health service where it is spent Financing Source Financing Agent Providers Functions NHA describes the flow of health funds

Financing Sources provide funds for health care Answers “Where does the money come from?” E.g., MOF, households, donors Financing Source Financing Agent Providers Functions NHA describes the flow of health funds

Financing Agents have control over how funds are used Answers “Who manages and organizes the funds?” Answers “What is the burden of financing on households?” E.g., MOH, insurance companies Financing Source Financing Agent Providers Functions NHA describes the flow of health funds

Providers provide/deliver the health service Answers “Where did the money go?” E.g., hospitals, clinics, health stations, pharmacies Financing Source Financing Agent Providers Functions NHA describes the flow of health funds

Functions are the actual services delivered Answers “What type of service was actually consumed?” E.g., curative care, preventive care, medical goods, administration Financing Source Financing Agent Providers Functions NHA describes the flow of health funds

19 The HIV Subaccount Total Health Expenditures THE general Subaccount areas are pieces of the total health expenditure “pie” THE HIV THE general

What questions do HIV Subaccounts answer? Tracks all health expenditures related to HIV through the four dimensions Source Where does the money come from? Agent Which entities manage and allocate HIV resources? What is the burden of financing on PLHIV? Provider and function What are the end uses of financiers ’ contributions?

Why Produce NHA and HIV Subaccounts? Areas of policy application: Design, implement, and monitor health and HIV programs Articulate strategic objectives Increase transparency and strengthen governance Specific country examples: Vietnam: building sustainable financing for HIV programs Egypt: monitoring insurance and financial risk protection Botswana: comparing actual spending to policy commitments

Example 1: Vietnam (B)

Example 1: Vietnam (C) Complementary perspective with sustainability planning

Key Steps for the NHA Report Writing and Dissemination Data Analysis & Validation Data Collection Launch

Strategy for Institutionalization World Bank Definition of institutionalization for resource tracking data “Routine government-led and country-owned production and utilization of an essential set of policy relevant health expenditure data using an internationally accepted health accounting framework

Institutionalization Strategies for the Eastern Caribbean Build capacity in regional institutions to provide technical assistance for future rounds of NHA Less expensive than foreign technical assistance More ownership by region and countries University of West Indies Health Economics Unit Experienced in health financing, household surveys, country context Abt Associates uses focused training and learning by doing with guidance to transfer knowledge of NHA production and dissemination

Increasing UWI-HEU Capacity to Produce NHA June 2012: Abt NHA Training and collaboration on NHA launch in SKN and Dominica July 2012: Learning by doing: Collaboration on data collection in SKN and Dominica August 2012: Collaboration on analysis and validation in SKN and Dominica

Next Steps in Capacity Building for Regional Institutionalization of NHA Collaborate with HEU to complete production and dissemination of NHA data in SKN and DOM Conduct independent household health expenditure and utilization surveys Conduct small expenditure surveys of people living with HIV Produce dissemination materials and share with stakeholders; discuss relevance for country and region Allow HEU to lead process in SVG Apply lessons learned to solidify training with minimal guidance from Abt Associates

NHA Production in SKN Successes Responded to demand Produced preliminary results for non-household expenditures Spread awareness of NHA data and their value in policy making for public, private and non-profit stakeholders Built capacity to provide technical assistance for NHA production at regional institution to ensure potential for regular production of high quality data Next Steps Complete household health expenditure and utilization survey Complete PLHIV expenditure survey Finalize NHA data results Disseminate results and discuss policy implications with stakeholders

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Thank you! Areas for urgent attention NHA for health financing reform Need for health financing road map Regional health financing committee? USAID/Abt/UWI as health financing technical partner USG funding has HIV strings attached (?) – need to find ways to link NCDs and HIV agenda, be creative in what constitutes financial sustainability Better coordination with PAHO 31