1 |

Health System Financing in Guinea,

Liberia and Sierra Leone: Overview

David B Evans, Director

Health Systems Governance & Financing

Prepared by B. Mathivet & J. Kutzin using data from country health account studies & the Global Health Account Database

2 |

Total Health Expenditure, per capita (PPP, int. $), 2000-2013 Rising, some faster than regional average

0

50

100

150

200

250

1998 2000 2002 2004 2006 2008 2010 2012 2014

Guinea Liberia Sierra Leone Median, 15 countries WCA

http://apps.who.int/gho/data/node.main.484?lang=en

$205: Sierra Leone

$102: Liberia

$67: Guinea

OOP due to health expenses: 67% Guinea 21% Liberia; 76% Sierra Leone

3 |

Total Health Expenditure and External Funding

2000-2012

0

10

20

30

40

50

60

70Liberia

Domestic resources in USD at ER External resources in USD at ER

0

5

10

15

20

25

30

35Guinea

Domestic resources in USD at ER External resources in USD at ER

0

20

40

60

80

100

120Sierra Leone

Domestic resources in USD at ER External resources in USD at ER

4 |

Health Expenditure/capita, main components, 2012

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

Other HE / capita (USD atER)

OOPS / capita (USD at ER)

GGEH / capita (USD at ER)

5 |

0

50

100

150

200

250

300

350

400

450

500

550

600

650

0

5

10

15

20

25

Eritr

ea

Angola

Sao T

om

e a

nd P

rincip

e

Kenya

Chad

Cong

o

Nig

eria

Gu

inea

Equato

rial G

uin

ea

Ga

bon

Gu

inea-B

issau

Côte

d'Iv

oire

Bots

wa

na

Cam

ero

on

Mozam

biq

ue

Cabo

Verd

e

Senega

l

Gh

ana

Maurita

nia

Com

oro

s

Mauritius

Ugan

da

Ta

nzania

Benin

Nig

er

Sudan

Seychelle

s

Eth

iopia

Centr

al A

fric

an

Rep

ublic

Ga

mbia

Burk

ina F

aso

Sie

rra L

eone

Mali

Madaga

scar

DR

C

South

Afr

ica

Buru

ndi

Nam

ibia

Djib

outi

Lesoth

o

To

go

Za

mb

ia

Mala

wi

Sw

azila

nd

Lib

eria

Rw

an

da

GGHE as % GGE & GGHE per capita at ER (2012)

GGHE as % GGE (2012) GGHE per capita USD at ER (2012)

Low public spending

Abuja target: 15% of GGE dedicated to health

7%

12% 19%

86USD: per capita estimate for a basic benefit package

9USD 16USD

20USD

6 |

Direct Out-of-Pocket Payments are

high

0

10

20

30

40

50

60

70

80

90

Sey

chel

les

Moz

ambi

que

Bot

swan

a

Nam

ibia

Sou

th A

fric

a

Sw

azila

nd

Mal

awi

Leso

tho

Gam

bia

Rw

anda

Cab

o V

erde

Libe

ria

Zam

bia

Con

go

Ang

ola

Bur

undi

Gha

na

Mad

agas

car

Tan

zani

a

DR

C

Mau

ritan

ia

Sen

egal

Bur

kina

Fas

o

Djib

outi

Tog

o

Eth

iopi

a

Gab

on

Gui

nea-

Bis

sau

Equ

ator

ial G

uine

a

Com

oros

Ben

in

Cen

tral

Afr

ican

Rep

ublic

Mau

ritiu

s

Ken

ya

Uga

nda

Sao

Tom

e an

d P

rinci

pe

Erit

rea

Cha

d

Nig

er

Côt

e d'

Ivoi

re

Mal

i

Cam

eroo

n

Nig

eria

Gui

nea

Sud

an

Sie

rra

Leon

e

Out of pocket expenditure as % of THE (2012)

7 |

A point on ODA (2/2)

Source: OECD-DAC

0

20

40

60

80

100

120

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Liberia

Other (Million USD at ER)

MDG6, reproductive health and family planning (Million USD at ER)

0

20

40

60

80

100

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Sierra Leone

Other (Million USD at ER)

MDG6, reproductive health and family planning (Million USD at ER)

0

10

20

30

40

50

60

70

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Guinea

Other (Million USD at ER)

MDG6, reproductive health and family planning (Million USD at ER)

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A point on ODA (1/2)

Country MDG 6

Reproductive health &

family planning

Health policy & management

Other health purposes

Distribution of funding

Guinea 54% 16% 16% 14%

Liberia 43% 12% 11% 34%

Sierra Leone 29% 23% 18% 30%

Source: OECD-DAC, disbursements

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The economy, government and private capacity to

spend is weakened by Ebola

Slower growth

means lower

government

revenues

Many cannot go to

work, food prices

increased

> higher occurrence of

catastrophic health

expenditure expected

Disruption of health

services may trigger

higher and more severe

morbidity

> Greater burden for the

health system

Significant external

assistance is

required, long term,

broadly allocated to

all parts of health

and health systems

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The Macroeconomic Situation : Growth

0.0

5.0

10.0

15.0

20.0

25.0

2013 2014 2015 2016

Guinea - Gross domestic product, constant prices(%change) Previous Estim.

Guinea - Gross domestic product, constant prices(%change) Current Estim.

Liberia - Gross domestic product, constant prices(% change) Previous Estim.

Liberia - Gross domestic product, constant prices(% change) Current Estim.

Sierra Leone - Gross domestic product, constantprices (% change) Previous Estim.

Sierra Leone - Gross domestic product, constantprices (% change) Current Estim.

Growth rate

Source: IMF World Economic Outlook Database (October 2014). Pre-crisis estimates extracted from Country Missions Reports 14/298, 14/299 & 14/300 released sept. 29th 2014.

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More on Macro Situation : inflation

5.0

6.0

7.0

8.0

9.0

10.0

11.0

12.0

13.0

2013 2014 2015 2016

Guinea - Inflation, average consumer prices(% change) Previous estim.

Guinea - Inflation, average consumer prices(% change) Current estim.

Liberia - Inflation, average consumer prices(% change) Previous estim.

Liberia - Inflation, average consumer prices(% change) Current estim.

Sierra Leone - Inflation, average consumerprices (% change) Previous estim.

Sierra Leone - Inflation, average consumerprices (% change) Current estim.

Inflation rate

Source: IMF World Economic Outlook Database (October 2014). Pre-crisis estimates extracted from Country Missions Reports 14/298, 14/299 & 14/300 released sept. 29th 2014.

12 |

The Macroeconomic Situation: budget deficits

0.0

2.0

4.0

6.0

8.0

10.0

12.0

2013 2014 2015 2016

Guinea - Budget Deficit (%GDP) Previousestim.

Guinea - Budget Deficit (%GDP) Currentestim.

Liberia - Budget Deficit (%GDP) Previousestim.

Liberia - Budget Deficit (%GDP) Currentestim.

Sierra Leone - Budget Deficit (%GDP)Previous estim.

Sierra Leone - Budget Deficit (%GDP) Currentestim.

Budget deficit as % GDP

Source: IMF World Economic Outlook Database (October 2014). Pre-crisis estimates extracted from Country Missions Reports 14/298, 14/299 & 14/300 released sept. 29th 2014.

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Conclusions (Unwritten Implications)

Funds for health insufficient to ensure universal access to even a

minimum set of interventions except perhaps Sierra Leone

Don't have good picture of costs of "revitalizing" health systems

External funding has increased particularly in Liberia and Sierra

Leone, but very highly skewed to MDGs, particularly MDG 6 –

more needed

Government health expenditures low, insufficient to protect

people from financial consequences of illhealth – high out of

pocket payments

Macroeconomic projections determining how much countries can

spend in the future are not promising

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Spare Slides

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Communities are crucial to tackle

Ebola… …yet they have limited power when it comes to Health Financing.

Due to its small scale and voluntary nature, CBHI:

- Only covers a small portion of the population.

- Gives access to few benefits

- Does not provide incentives for broad health systems reforms.

> Only higher state budget allocation for health can bring greater financial

protection to all, and trigger positive changes in quality and efficiency

Small

pools

Low

financial

capacity

Small

benefit

packages

Low

attracti-

veness

Low rates,

voluntary

contribution