1 |

Building institutions for an effective transition towards UHC

Dr Agnès Soucat

Health Systems Governance & Financing

WHO

Sustainability and Transition Meeting

30 March 2017

2 |

TRANSITION FROM AID

Many (most?) countries can expect a decline in aid

Others experience other types of transition: health financing,

epidemiological, demographic, economic, etc

Not a money issue ?

ALL countries need to strengthen public finance

Strengthening institutions is key

3 |

NOT A MONEY ISSUE?

4 |

”a transition in which the per capita amount of external

financing declines while indicators of (1) overall population

health and (2) overall access to health services do not

decline.”

Bill Savedoff

5 |

IS TRANSITION REALLY ABOUT MORE MONEY

Domestic and External Resources for

Health in Fragile States (2011-13)

Domestic and External Resources for

Health in non-fragile LICs (2011-13)

Sources:

1. OECD DAC2011-2013 (28 Fragile States, 10 billion constant 2013 USD/7.57 per capita, 26 non-fragile LICs (20 billion constant 2013 USD/10.45 per capita) : other includes donors who gave less than 100 M$; disbursement-base data to a country from a donor and not include multi-

country donations; World Bank “HARMONIZED LIST OF FRAGILE SITUATIONS FY15” was used for the fragile status.

2. WHO Global Health Expenditure Database (24 Fragile States, 24 non-fragile LICs): external resource represents health expenditure from external source as percentage of total health expenditure; domestic resource includes both private and public health expenditures

6 |

Public expenditure on health per capita in transitioning countries is above the lower-middle income average

UMIC average

LMIC average

0

500

1,0

00

1,5

00

2,0

00

2,5

00

Co

nsta

nt

201

1 in

tern

ation

al$

PP

P

Ba

ng

lad

esh

La

o P

DR

Tim

or-

Le

ste

Su

da

nN

ige

ria

Ph

ilip

pin

es

Ind

on

esia

Pa

pu

a N

ew

Gu

ine

aV

an

ua

tuG

ha

na

Syri

an

Ara

b R

ep

ub

licS

olo

mo

n I

sla

nd

sV

ietn

am

Uzb

ekis

tan

Arm

en

iaS

ri L

an

ka

Ge

org

iaG

ua

tem

ala

Nic

ara

gu

aK

irib

ati

An

go

laH

on

du

ras

Mo

ldo

va

Ca

bo

Ve

rde

Bo

livia

Gu

ya

na

Tu

rkm

en

ista

nB

hu

tan

Aze

rba

ijan

Sa

mo

aT

on

ga

Ja

ma

ica

Ukra

ine

Sw

azila

nd

El S

alv

ad

or

Alb

an

iaM

on

go

liaB

eliz

eG

ren

ad

aS

t. L

ucia

Do

min

ica

n R

ep

ub

licP

eru

Pa

rag

ua

yIr

aq

Do

min

ica

Ga

bo

nM

au

ritiu

sT

un

isia

Ira

n,

Isla

mic

Re

p.

St.

Vin

ce

nt

& G

ren

ad

ine

sS

uri

na

me

Ecu

ad

or

Bo

tsw

an

aN

am

ibia

So

uth

Afr

ica

Ma

rsh

all

Isla

nd

sM

ala

ysia

Tu

va

luK

aza

kh

sta

nA

lge

ria

Be

laru

sC

olo

mb

iaB

ulg

ari

aS

erb

iaT

ha

ilan

dR

om

an

iaC

osta

Ric

aP

an

am

aC

ub

a

Source: WHO Global Health Expenditure Database

Public expenditure on health per capita, 2014

UMIC average

LMIC average

7 |

Also as a share of GDP….

02

46

81

01

21

41

6

Perc

en

t

Tim

or-

Le

ste

Ba

ng

lad

esh

Ind

on

esia

La

o P

DR

Nig

eri

aA

ze

rba

ijan

Tu

rkm

en

ista

nP

hili

pp

ine

sG

eo

rgia

Su

da

nS

ri L

an

ka

Arm

en

iaS

yri

an

Ara

b R

ep

ub

licA

ng

ola

Gu

ate

ma

laM

ala

ysia

Ga

bo

nV

ietn

am

Ma

uri

tiu

sK

aza

kh

sta

nU

zb

ekis

tan

Mo

ng

olia

Gh

an

aJa

ma

ica

Gre

na

da

Ira

n,

Isla

mic

Re

p.

Do

min

ica

n R

ep

ub

licA

lba

nia

Su

rin

am

eB

ots

wa

na

Pe

ruIr

aq

Va

nu

atu

Ca

bo

Ve

rde

St.

Lu

cia

Be

laru

sB

oliv

iaD

om

inic

aN

ica

rag

ua

Ukra

ine

Be

lize

Tu

nis

iaE

l S

alv

ad

or

Ho

nd

ura

sS

ou

th A

fric

aT

on

ga

Bh

uta

nS

t. V

ince

nt

& G

ren

ad

ine

sG

uya

na

Sa

mo

aR

om

an

iaP

ara

gu

ay

Ecu

ad

or

Pa

pu

a N

ew

Gu

ine

aB

ulg

ari

aM

old

ova

Sw

azila

nd

Alg

eri

aN

am

ibia

Co

lom

bia

Th

aila

nd

So

lom

on

Isla

nd

sP

an

am

aS

erb

iaC

osta

Ric

aK

irib

ati

Cu

ba

Ma

rsh

all

Isla

nd

sT

uva

lu

Source: WHO Global Health Expenditure Database

Public expenditure on health as % of GDP, 2014

UMIC average

LMIC average

8 |

Still progress can be made to prioritize health in some transitioning countries

05

10

15

20

25

30

Pu

blic

exp

en

ditu

re o

n h

ea

lth a

s %

of to

tal go

vern

men

t exp

en

ditu

re

500 1000 5000 25000 75000GDP per capita, PPP 2011 $

Source: WHO Global Health Expenditure DatabaseRed signifies Global Fund or Gavi transition country

Public expenditure on health as % oftotal government expenditure versus GDP per capita, 2014

9 |

A PUBLIC FINANCIAL MANAGEMENT AGENDA

10 |

Focus on revenues AND expenditures

Health programs and their partners each addressing these issues and approaching Finance

Ministries

– …for sustainability of their program (HIV/AIDS, NCDs, NTDs, nutrition, RMNCAH, TB, malaria,…)

Sustainability is not only a revenue question; we also have to think about managing

expenditures to get better results from our spending

– “Can’t just spend your way to UHC”

Enabling efficiency

– Streamline system architecture across programs while ensuring good results

– Invest in underlying systems

11 |

WHAT TRANSITION IS REALLY ABOUT …

Enabling effective domestic revenue collection and allocation for the

sector

Managing expenditures better to get better results

Building or strengthening organizations and processes that support and

enable system efficiency and performance

Streamlining processes across programs to end fragmentation, while

ensuring good results

12 |

INSTITUTIONS

13 |

TRANSITION FROM MDGs to SDGs

MDGs stimulated fragmentation: separate plans, budget, funding,

procurement, monitoring, etc.

SDG targets may lead to continued emphasis on vertical approaches:

more separate plans, monitoring mechanisms, funding streams and

implementation efforts

How to avoid the same vertical trap? Health Systems for UHC

The UHC target can provide “umbrella” to enable move away from silos and

fragmentation

14 |

SDGs (Impact)

UHC (Outcome)

Health System Strengthening/ Performance (Input/Output)

Health System Strengthening

Achieve Universal Health Coverage All people and communities receive the quality health services they need,

without financial hardship

SDG 1: No poverty

SDG 4: Quality Education SDG 5: Gender Equality

SDG 16: Inclusive societies SGD 8: Inclusive economic growth

and decent jobs

SDG 3: Equitable health outcomes and wellbeing; Global public health security

and resilient societies

Investing in Health Systems to reach the SDGs

15 |

Fit for context – Fit for purpose

Health Systems

Building Health System Foundations

Strengthening Health System

Institutions

Supporting Health System

Transformation

16 |

Focus on increasing overall tax revenues at the core of transition agenda

05

10

15

20

25

30

35

Tax r

eve

nu

e a

s %

of G

DP

500 1000 5000 25000 75000GDP per capita, PPP 2011 $

Source: World Bank World Development IndicatorsRed signifies Global Fund or Gavi transition country

Tax revenue as % of GDP, 2014

17 |

Institution building (1): it is about citizens

Domestic funding is about citizens voice

Collective financing is driven by choices of taxpayers in terms of revenue generation, and

budget allocations

Efficiency is driven by accountability

18 |

Institution building (2): it is about the law

Strengthening critical regulation and legal frameworks

–Procurement

–Public Financial Management

–Human Rights and Entitlements

–Accreditation/Regulation of medical products

19 |

Building governance capacity of Ministries of Health --- often weakened by parallel governance structures – Not only policy capacity but also implementation capacity

– Norms, standards and regulation

– HTA and strategic purchasing

– Monitoring and evaluation

– Using evidence for policy; implementation research

Comprehensive, evidence-based health sector strategies, formulated through a participatory approach – Vertical programs integration

– Subsector (HRH, pharmaceuticals etc) integration

Institution building (3): it is about agencies’ capacity

20 |

Governance - Examples

Institutuional & legal assessment

Develop organizational capacity for reforms including

legal framework

Policy dialogue on accountability / “citizen’s voice” at

national, sub-national or local level (e.g. NHAs)

Design needed institutional reforms

Support setting institutional arrangements to better inform

policy

Annual transparent reviews

Financing - Examples

Health financing diagnostic analysis

Strengthening resource tracking methods and capacities

Diagnosing potential areas for technical efficiency gains

Advice on design & impl° planning for nat health

financing strategy

Institutional support to nat./Region public health/econ.

training entities

Health financing training

Workforce - Examples

Health Labour Market analysis

Support the development of health workforce strategies

aligned with NHPSPs

Support the inter-ministerial dialogue on health workforce

Support the development of curricula, pre-service and in-

service education programmes

Strength institutional capacity for HRH stewardship

Regulatory frameworks

Pharma./med. products - Examples

Policy dialogue on Good Governance of pharmaceutical

systems including regulation, procurement and supply

Policy dialogue on access to ess. medicines and health

products, incl. review of policy options for supply systems

& local production

Education and training of health care professionals in

order to support the implementation of national medicines

policies and strategies

Information - Examples

Policy dialogue to ensure availability and accessibility of

comprehensive disaggregated high-quality data

Support interoperability and integration of HIS systems

to reduce fragmentation and ensure communication,

exchange and use of health data (e.g. Nat Obs)

Strengthen analytical capacity and engage national stat.

offices to support MoH in monitoring SDGs

Service Delivery - Examples

Policy dialogue on national quality and safety policy and

strategy

Design and evaluate options to re-orient the model of

care and for successful care coordination

Support to hospital and public health institute

strengthening programmes

Support for key health systems functions in AMR national

action plans (e.g. antibiotic stewardship, infection

prevention, research and development)

Institution – examples of interventions

21 |

Transition is about Institutions

Not a money issue

ALL countries need to strengthen public finance

Strengthening institutions is key