Bruno Meessen, ITM Brussels, December 2012 Universal Health Coverage in LMICs: a major drive for the BTC operations? Bruno Meessen, ITM Brussels, December 2012

UHC: a goal “Everyone should be able to access health services and not be subject to financial hardship in doing so”. (WHA resolution 58.33 2005) Access to effective services Equity Protection from CHE and for income loss

Three problems (WHO Report) Availability of resources Overreliance on direct payment Inefficient and inequitable use of existing resources

Insufficient resources Better tax collection. Greater share of te public budget for the health sector. Innovative financing – e.g. sin tax. ODA: more of it => create trust by delivering results. Q1: How can Belgium / BTC contribute at this level?

Overreliance on direct payment Develop prepayment scheme – little evidence supporting voluntary schemes. Possible options: User fees + compulsory insurance + subsidy for those unable to pay. Tax-based system and reduction of user fees + subsidy for those unable to pay. Q2: how does BTC contribute to that?

A specific issue: combine different schemes

Inefficient use of resources Allocative efficiency: public funding to priority services? Reimbursment of most cost-effective technologies? What about the private sector/OOP? Technical efficiency: are we getting the most from the production factors: technology / infrastructure / personnel and their combination? “Transactional efficiency”: transaction costs, corruption, poor coordination among funding sources and interventions. Q3: how does BTC contribute to that?

UHC in LMICs: things which can be done A few thoughts: at global level at regional level at national level at project level

Background

Funding to (U)HC in 6 countries

Cambodia Aid is much less important than we think. The present is OOP, the future is national public funding.

External resources to health (2005)

At global level: Keep the momentum with agenda setting Benefit from the leadership of MICs (Thailand, Mexico, China…). Build alliance with ‘agenda setters’ – e.g. Rockefeller Foundation, WHO. Exchange knowledge on the challenge of agenda setting at different levels. Q4: How can BTC / Belgium contribute to this global agenda setting process?

At regional level Agenda setting is not enough. There have been in the recent past, several ‘enthusiastic/naïve’ UHC-related initiatives which have destabilized health systems (Meessen et al 2011). Substantial efforts have to be done in terms of sharing knowledge and experience on formulation and implementation of health care financing policies.

Generate and share knowledge Funding: UNICEF

Communities of Practice

Community of Practice – a definition “a group of people who share a concern, set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis” Wenger et al (2002)

transactional peripheral occasional active core group coordinator lurkers outsiders peripheral occasional experts alumni active beginners core group leaders coordinator sponsors 18

What communities of practice address ‘Silo mentality mindset’ that creates disconnections between the main actors of the health sector: Researchers Policy-makers Aid agencies Practitioners (Meessen et al, 2011) And those outside the health sector but important (!) like: Parliamentarians Civil society

The disconnections between actors Researcher/Scientists: select research questions relevant to their own niche tend to overlook implementation questions often under-invest in terms of knowledge transfer Policy makers: often reluctant to involve key stakeholders in their planning cycle long-established routines lead to rigidities in the decision-making process do not comply with their own planning cycle (lack of preparation and M&E of reforms) CoPs are a strategy to bring these actors together, providing a structure/platform for interaction Int. organiz. and aid agencies : recognize knowledge as a public good but often focus on explicit and codified knowledge, rather than on situated implementation Practitioners / frontline actors: usually do not take part in knowledge sharing (although they represent a potentially important source of information)

Maintain the focus on challenges www.healthfinancingafrica.org

Face to face events Morocco site visit to see the RAMED in action Parliamentary round table

Regional level Build coalition and networks, exchange with other experts, support regional initiatives, empower experts from the South… Q5: How could the BTC contribute more to these regional efforts? How could BTC be less its own silo?

National level: many challenges Availability of services all over the country Quality of services (public and private) Out-of-pocket payment. Equity across socio-economic groups Utilisation by the population Sustainability

National level: some determinants of these challenges Limited financial and technical resources. Leadership/ stewardship Governance of the various components of the health system / accountability. Allocative efficiency in the use of resources. Technical and transactional efficiency. Q6: how could the BTC / Belgium address these determinants?

National level: some ideas Consolidate the national momentum for UHC. Paris Declaration: how to enact it? “Les voies de la CTB sont impénétrables” Do not dictate solutions, bring a holistic perspective. Ensure that Belgium is committed to maximize benefits to the population. Greater attention to outcomes/results? Address bottlenecks.

Project level How to ensure UHC at project level (if it focuses on a region)? Consolidate or innovate? How not to be mainly the servant of the administrative rules? Spill-over effects (in terms of national capacity, research…). E.g. Cambodia. Q7: what is your experience?