Nouria Brikci Health economist/ health policy specialist Governance and Health March 2014

Plan of session 1. What is a functioning health system and why is it important? 2. Does governance matter in health? 3. How to test transparency/ accountability / VfM? 4. Are these tools enough? 5. Concluding remarks DD Month YYYY© 2011 Oxford Policy Management Ltd2

What is health? DD Month YYYY© 2011 Oxford Policy Management Ltd3 Source: WHO (2011)

Governance – a central issue Source: WHO (2000)4

5 You are a patient in Sierra Leone who needs care. Who will influence your ability to access quality health services?

10/3/20156 Patient How will health workers be paid? What is their incentive to deliver good services? Is the worker actually there? Practicing in private facilities? How much of government resources make it to health facility? Any loss in process? How efficiently are resources spent/ how equitably? How much power does MoH vs MoF have? How much power does IMF vs MoF have? What does it influence? How do donors influence decisions? Financing, HRH, delivery? Civil society/ community

Value For Money (VfM) – the transformation process DD Month YYYY© 2011 Oxford Policy Management Ltd7 Source: Smith, P. C. (2009). Measuring value for Money in Healthcare: concepts and tools. QQUIP. VfM = best possible outcome within a given budget

Tools to test transparency and accountability Public Expenditure Tracking Surveys is a quantitative exercise that aims to track the flow of public resources across various layers of administrative hierarchy, from the allocating agency to the intended beneficiary, and determine inefficiencies in the system and their magnitude. Sierra Leone: study shows that in 2006, 88.2% of the total value of essential medicines supplied by the District Medical Stores reached the primary health units (GoSL, 2007) Uganda: A survey of primary schools in Uganda revealed that only 13 percent of the per-student capitation grants made it to the schools in In 1995 for every dollar spent on nonwage education items by the central government, only about 20 cents reached the schools, with local governments capturing most of the funding. DD Month YYYY© 2011 Oxford Policy Management Ltd8

National Health Accounts summarising, describing, and analysing financing of national health systems. NHA tracks the flow of all health funds (public, private, and donor) in a health system, from their financing sources to their end uses. Egypt: NHA showed that Egypt spent 4 percent of its GDP on health care, with household out-of-pocket expenditures amounting to almost 50 percent of total expenditures and the Ministry of Health and Population accounting for less than 20 percent of total expenditures. Burden of these expenditures very inequitably distributed, with the poor spending the largest share of income on care. (Partners for Health Reforms, 2003) Public Expenditure Reviews examine appropriateness of policies and reforms in developing countries to achieve poverty reduction and examine effectiveness, efficiency, and equity impacts achieved or not through public investment in the sector under review. Rwanda - PER in Rwanda revealed inequitable allocation of healthcare expenditure to HIV DD Month YYYY© 2011 Oxford Policy Management Ltd9

DD Month YYYY© 2011 Oxford Policy Management Ltd10 Liberia PER (Lievens 2012)

Quantitative Service Delivery Surveys : survey the efficiency of service provision. They can be used for the analysis of public expenditure management reforms, service-delivery reforms, reforms to improve the efficiency of public expenditure, as well as cross-cutting public sector reforms Benefit Incidence Analysis in the health sector examines who benefits from expenditure on health care. It usually relates to public expenditure and is concerned with the issue of how effectively governments are able to target their limited resources towards meeting the needs of the poor, as they usually profess to do. DD Month YYYY© 2011 Oxford Policy Management Ltd11

DD Month YYYY© 2011 Oxford Policy Management Ltd12 Source: AfDB (2014) Tools to test VfM

Tools to test transparency/ accountability of these relationships DD Month YYYY© 2011 Oxford Policy Management Ltd13 Source: OPM (2014)

Is seeking transparency enough? DD Month YYYY© 2011 Oxford Policy Management Ltd14

Governance and health financing Who funds health? – Shift from governments, to aid organisation, to foundations (Gates in particular) / INGOs: – own shifting priorities (HIV, MNCH, malaria, innovation, private sector) – – Vertical vs horizontal programmes :eg HIV vs PHC FADs – Revenue raising mechanism (User fees to universal coverage) – Pooling of resources (CBHI) – Purchasing of services (PBF) Governance and Health service delivery – New Public Management Theory (WDR 1993)  Changing role of the state => from delivery to steward/ facilitator and regulator of market - decentralisation  Role of the private sector: in the 80s, public sector dominating – since then private sector increasingly advocated for (social franchising/ marketing, private provision)=> role of the market in healthcare DD Month YYYY© 2011 Oxford Policy Management Ltd15

Governance and health workers Who decides where health workers go? Impact of push and pull factors, particularly brain drain (international migration, to donors agencies, to INGOs)? Who decides what health workers do? Taskshifting? Community health workers in or out? Who decides how health workers are paid? Fads of PBF shifting incentive structures with little evidence to back it up DD Month YYYY© 2011 Oxford Policy Management Ltd16

DD Month YYYY© 2011 Oxford Policy Management Ltd17 Wastage monitoring framework (Dovlo, 2005)

Concluding remarks Governance of the health sector increasingly complex => many actors, many priorities Each health system block facing own challenges with governance Set of tools available to test those relationships useful but no magic bullet => need systemic coherence, coordination and direction DD Month YYYY© 2011 Oxford Policy Management Ltd18

Thank you