January – June 2005 • Volume 6, Number 1 • A magazine of the World Health Organization Regional Office for Africa

• Choosing Interventions that are • Scope and application of Cost Effective Health Economics • Poverty Reduction Strategy Papers • Health Economics Plan • Health Development and Planning • Health Financing in the African Region in the African Region 1 AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Contents 1

From the Regional Director’s Desk By Dr Luis Sambo

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Health Economics: scope and application in the African Region By Dr Joses Kirigia

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Overview of the Strategic Health Economics Plan for the WHO African Region (2006-2015) By Dr Paul-Samson Lusamba-Dikassa

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Health development planning in the African Region: a status report By Dr. Saidou Pathe Barry and Dr. Omer Ayayi Mensah

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Healthcare Financing in the African Region By Dr Rufaro Chatora

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Macroeconomics and Health: the way forward in the Region By Dr. Chris Mwikisa

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Long-term Perspectives Approach in National Health Strategic Planning By Dr. Anthony Mawaya

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Poverty Reduction Strategies Papers: an overview of their health component By Dr. Benjamin Nganda

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Choosing Interventions that are Cost-Effective: an aid to policy By Dr David Evans and Dr Tessa Tan-Torres Edejer

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The status of National Health Accounts in the African Region By Mr Takondwa Mwase

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Health financing reforms: the Nigerian experience By Dr Amos Petu

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Health financing reforms in Senegal By Dr Farba Lamine Sall

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Technical efficiency of health centres: Evidence from Sierra Leone By Mr. Ade Renner and Dr Joses Kirigia

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National health accounts development: the Namibian experience By Mr. William Kapenambili, Mr. Thomas Mbeeli and Mr. Ben Tjivambi

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Implementing the macroeconomics and health strategy: the Ghanaian experience By Mr. Sellasie Amah d’Almeid.a

COUNTRY REPORTS

The cover for this issue was designed by Mr. Henry Bastiene/HIP Seychelles Editing support was provided by Mrs Eva Ndavu at the Regional Office The African Health Monitor is a magazine of the World Health Organization Regional Office for Africa. It is published two times a year in English, French and Portuguese. Material contained in this publication does not, however, represent WHO’s views. Articles may be reproduced for non-commercial purposes. Please address all correspondence to: Samuel T. Ajibola – Editorial Coordinator African Health Monitor WHO Regional Office for Africa P.O. Box 6, Brazzaville, Republic of Congo Tel: + 47 241 39378; • Fax: * 47 241 E-mail: [email protected]

From the Regional Director’s Desk

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t is now widely accepted and acknowledged that poverty and ill-health are closely linked, even mutually re-enforcing, such that they generate a cycle of deterioration for those who suffer from them.

In many African countries, ill-health contributes directly to reduced productivity and loss of employment for the individuals, with disastrous consequences for dependents. The basic diagnostic point that good health is an integral part of development has therefore come to take centre stage in development thinking. This is because only healthy people can earn incomes, afford and seek medical care for themselves and their families, have better nutrition and experience more freedom to lead healthier lives. It is also a truism in our part of the world that heavy and increasing burdens of disease (old, new and reemerging) have conspired to disturb the health and development equation. The evidence is clear: the precipitous decline in life expectancy in much of Africa, mainly attributable to the HIV/AIDS pandemic, presents a graphic example of how health may deteriorate as societies face sudden disease-induced social and economic change. Classically, economic indicators have focused primarily on income poverty, whereas it is health indicators that actually provide a measure of the multidimensional nature of poverty.

term health planning have a place in the scheme of things? How seriously do our countries take health development planning? Are Member States making enough efforts to contextualize and adapt the Macroeconomics and Heath Report? Do they need national health accounts and cost-effective analyses to improve the choice and quality of health interventions? Should efficiency in Africa’s health services be prioritized? Indeed, is there a place for health economics in political governance? Just as, famously, war has been said to be too important to be left to generals alone, it can be argued that health is too crucial and complex to be left solely to medical doctors, health professionals and ministries of health. Health professionals and non-health professionals, including health economists, managers and social scientists could and should play an increasing role in health policy analysis, health systems design and generating evidence for better decision-making. This issue of the African Health Monitor, examines these and related issues. The articles should make interesting and compelling reading to all those who have an interest in a holistic approach to Africa’s development.

Happy reading.

Is it not time for a paradigm shift? To our rescue, hopefully, comes the flourishing field of health economics. This discipline covers most aspects of health, from conceptualizing the meaning of health, to studying how health institutions and markets function. What is health economics? Does Africa have a health economics plan? What are the meaning, impact and role of Poverty Reduction Strategy Papers? Does longAFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Dr Luis G. Sambo

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Health economics: Scope and application in the African Region Introduction Available resources are not always adequate to tackle the priority public health problems in a country. Therefore, it is necessary to ensure that available resources are used efficiently. Health economics is concerned with health maintenance choices in the context of resource scarcity. This article provides an overview of the scope of health economics and its application in the African Region. The discussion below refers to Figure 1.

Health, health indices and health determinants Boxes A and B in Figure 1 deal with a definition of health, its measurement and valuation, and its broader determinants (e.g. genetics, environmental factors, consumption patterns, education, income, capital). Social scientists define health as the ability to perform one’s expected societal roles or functions. Diseases inhibit a patient’s mobility, capacity for social participation, performance of usual activities (e.g. work or schooling), ability for self-care (especially during the severe stage) and causes pain and discomfort (psychological and physical) as well as anxiety and depression. Diseases deplete an individual’s quality of life (QoL) and length of life (LoL). Health indices combine changes in both QoL and LoL due to disease onset or intervention. Examples of such indices are quality adjusted life year (QALY), disability adjusted life year (DALY) and disability adjusted life expectancy (DALE). The effect of health interven-

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tion will be the difference between total expected DALE with intervention and total expected DALE without intervention. Detailed nation-wide DALY (burden of disease) studies have been undertaken in Algeria, Mauritius, South Africa and Zimbabwe.

*Dr Joses Kirigia

Supply of health care Individual and household demand for health care

Supply refers to the maximum quantity of services health providers are able to produce and are willing to sell at the going market prices (Box D). The quantity willingly supplied during a specified period of time is positively related to market prices, ceteris paribus. A higher price gives profit motivated producers (e.g. private health care providers) the incentive to increase production. In addition, in the short run, the quantity supplied is affected by input prices, technology and prices of other goods. Underlying the supply of any good or service is the production function, that is, the relationship between the output of that good or service and the input used to produce it. If the output were outpatient and inpatient care, then included in the input would be the number of physicians, nurses, technicians, pharmaceutical supplies, non-pharmaceutical supplies, beds, space, etc.

Scarcity necessitates choices of many different forms. Individuals (households) must decide how to use their resources: physical (e.g. land, equipment) and intellectual (e.g. knowledge and skills) assets, material wealth and labour time. Box C considers the analyses of the health-related demands and choices of individuals and households. Choice of a particular commodity or course of action (e.g. whether or not to seek care) is usually assumed, in health economics (and in economics generally), to be a function of personal socioeconomic characteristics (e.g. age, marital status, religion, health education, secular education, income, risk attitudes, epidemiological environment, genetic endowment, etc), and commodity-level attributes (e.g. service price, travel cost to service source, waiting time at the source, perceived effectiveness of service, etc). In the African Region, demand analysis has been used to explain individual choice of source of health care; use of condoms to prevent HIV infection; use of addictive substances (cigarettes and alcohol); choice of contraceptives;1 toilets ownership; health insurance ownership.

Even for public health care providers who are service-driven, it is critically necessary to use them efficiently for maximum output, given that health input is in limited supply. Inefficiencies represent wasted opportunities for improving at least one citizen’s health status at no extra cost.

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Jones AM and Kirigia JM, The determinants of the use of alternative methods of contraception among South African women, Applied Economics Letters, 7:501–504, 2000. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Health economists use mathematical (linear, integer and goal) programming and econometric methods to estimate efficiency scores and excess inputs (or output deficit) for individual decisionmaking units, e.g. hospitals, health centres, etc. Data envelopment analysis (DEA) has been used in estimating the magnitude of inefficiencies among individual hospitals and clinics in Ghana, Kenya2, Namibia, Sierra Leone, South Africa3 and Zambia. Similar analyses have been undertaken in Nigeria using econometric methods.

Microeconomic evaluation at prevention and control level Economic evaluation is a comparative analysis of costs and consequences of at least two or more interventions into a public health problem. Cost-effectiveness, cost-utility, and cost-benefit analysis of alternative ways of delivering care (e.g. mode, place, timing or amount) at all phases (detection, diagnosis, treatment, after-care) takes place in Box F.

Cost-effectiveness analysis Cost-effectiveness analysis (CEA) compares two or more interventions, measuring the input in monetary terms and the outcome in natural or physical units. CEA is appropriate when there is one, unambiguous objective of the intervention(s) and therefore a clear dimension along which effectiveness can be assessed. CEA data requirements are direct costs, indirect costs (time lost from work), intangible costs (anxiety, pain) and externality costs; and outcome measured in natural units such as deaths averted, cases detected and treated, etc. Decision criteria require choice of the intervention with least incremental cost-effectiveness ratio. CEA does not resolve the problem of option selection whenever different interventions yield more than one kind of beneficial effect with the mix of benefits differing between options. In the Region, there have been CEA of tuberculosis, malaria4, schistosomiasis, HIV/AIDS, distance education5 and school health programmes, among others. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Cost utility analysis Cost utility analysis (CUA) is a method that compares two or more interventions, measuring input in monetary terms and the outcomes in a health index, e.g. QALY, DALY, and DALE. It is appropriate when the problem facing, for example, a schistosomiasis decisionmaker is: “From the societal perspective, does drip mollusciciding, household health education visits, vented improved pit latrines, mass population chemotherapy with oxamniquine, or mass population chemotherapy with praziquantel promise the highest incremental health improvement per incremental cost?” CUA undertakes costing in the same way as CEA. On the effectiveness side of the equation, data requirements will depend on the health index that one decides to use. CUA decision criteria dictate that the intervention with the least incremental cost-utility ratio should be chosen. CUA methodology can only be used in pursuit of production efficiency, but not allocative efficiency, mainly because cost and benefits are not measured in the same manner. CUA has been used in Kenya to identify the optimal schistosomiasis intervention strategy. 6

Cost-benefit analysis Cost-benefit analysis (CBA) is the technique employed in identifying, quantifying and valuing in money all important costs and consequences to society of health interventions. It is appropriate to use when the issue is whether health intervention benefits are greater or equal to costs. An example of a CBA policy question is: “From the social perspective, is it worth continuing the status quo HIV/AIDS preventive intervention instead of STD treatment, social marketing of condoms, safe blood provision or needle exchange/bleach provision options?” Within CBA methodology intervention benefits are measured in money using the “human capital” approach, the “implied values” approach or the “willingness to pay” approach. The CBA decision rule recommends choice

of the intervention with the highest net present value. CBA issues revolve around measurement and valuation of intervention benefits, valuation of statistical life, derivation of a social welfare function from individual utility functions, incorporation of equity concerns, and uncertainty and time preference. CBA has been used to appraise schistosomiasis interventions in Kenya.7

Macroeconomic analysis Disease and development A disease has a number of negative effects on development (Box G). Firstly, it depletes quality and quantity of human resources, and thus, economic productivity. Secondly, it relegates its victims to a culture of social and economic dependence leading to a reduction in their self-esteem or self-worth. Lastly, the condition deprives its victims of the freedom from avoidable ill-health and from escapable mortality. The WHO Commission on Macroeconomics and Health, employing regression methods, demonstrated that investments in health would boost economic growth in developing countries. Use of similar methods in the Region revealed that maternal mortality and

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Kirigia JM, Sambo LG and Emrouznejad A, Technical efficiency of public hospitals in Kenya, Journal of Medical System, 26(1): 39–45, 2002. 3 Zere EA, Addison T and McIntyre D, Hospital efficiency in sub-Saharan Africa: evidence from South Africa. South African Journal of Economic. 69(2): 336–358, 2000. 4 Goodman C, Coleman P and Mills A, Economic analysis of malaria control in sub-Saharan Africa. Geneva: Global Forum for Health Research, 2003. 5 Kirigia JM, Sambo LG, Phiri M et al, Cost-effectiveness analysis of establishing a distance-education programme for health personnel in Swaziland, African Journal of Health Sciencies, 9(3-4): 3–15, 2002. 6 Kirigia JM, Cost-utility analysis of schistosomiasis intervention strategies, Environment and Development Economics, 3(3): 319–346, 1998. 7 Kirigia JM, Sambo LG and Kainyu LH, A costbenefit analysis of preventive schistosomiasis interventions, African Journal of Health Sciences, 7(3–4): 4-10, 2000.

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disaster-related deaths had a significant negative impact on the gross domestic products of individual countries.8 Health economics is useful in estimating the effects of morbidity (and mortality) on economic growth (including volume or value of trade); disease and levels of self-esteem among individuals and communities; disease and degree of freedom in making various choices; and health provider responsiveness to patient’s rational expectations.

Disease and poverty Poverty predisposes the poor to disease in through inaccessibility to preventive information and commodities; “forced” migration (in search of paid jobs), and need to embark on high-risk economic

behaviour (e.g., commercial sex) and social behaviour that increases the risk of infection (e.g. alcohol consumption and drug use). Once established, disease exposes its victims to income poverty via productivity losses (resulting from reduced stamina, absenteeism and death); increased dependency ratio, as the productive portion of the population decreases; increased number of orphans, and hence, the cost of taking care of them; catastrophic health care costs, and hence, diversion of resources from economic growth-generating activities; overload of national health systems, and hence, their capacity to respond effectively to increased needs. Econometric methods can be used to study the impact of disease on various

forms of human deprivations. Such studies would inform policy-makers on how various specific disease interventions impact on poverty levels.

Programme planning, budgeting, monitoring and evaluation mechanisms A plan is a course of action consisting of objective(s), target(s), expected result(s), activities, resources, and a monitoring and evaluation element. Monitoring is meant to keep track of the

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WHO, Macroeconomics and health: Investing in health for economic development, Geneva, World Health Organization, 2001.

Figure 1 : Scope of Health Economics [A] What is health? how can it be measured and valued? Perceived attributes of health; health status indices; value of life; utility scaling of health.

[B] What influences health (other than health care)? Genetics; water; sanitation; consumption patterns; education;income; culture; housing; clothing; food; human and physical capital; etc.

[C] What factors influence demand for promotive, preventive and curative health care? Influences of A + B on care-seeking behaviour; barriers to care seeking (price, time, psychology); agency relationship; need; altruism; insurance; quality of care.

[D] What factors influence supply of health care? Costs of production; alternative production techniques; input substitution; markets for health inputs (human resources, drugs, equipment, etc); provider remuneration methods and incentives.

[E] What factors determine health care market? Money prices; time prices; waiting lists and other non-price rationing systems as equilibriating mechanisms and their effects on health facility services.

[F] Microeconomic evaluation at prevention and control level Cost-effectiveness, cost-utility, and cost-benefit analysis of alternative ways of promoting health while preventing, detecting, diagnosing and treating disease.

[G] Macroeconomic analysis Health and development (including trade/globalization, debt-forgiveness); Iil-health; poverty.

[H] Planning, budgeting, regulation and monitoring mechanisms Use of planning in pursuit of efficiency; interplay of budgeting, human resource allocations, regulation and the incentive structures they generate; monitoring efficiency in use of resources to achieve results.

[I] Sectoral formative and summative evaluation Health sector performance in stewardship, financing (revenue collection, fund pooling, purchasing), resource generation and provision of health services; health sector performance in enhancing health status, responding to clients’ non-medical expectations and fair financing.

Source: Adapted from Williams AH, Welfare economics and health status measurement. In Health, economics and health economics (ed. van der Gaag J and Perlman M), Amsterdam: North-Holland, pp. 271–281, 1981.

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AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

progress in implementation of planned activities, to assess the effectiveness of the programme in achieving expected results, to keep track of the rate of resource use and to identify factors that enhance or inhibit implementation (Box H). Evaluation is the assessment of effectiveness, relevance, quality, adequacy, utilization and equity of a public health programme9 (Box I). The effectiveness of public health programmes largely hinges on the effectiveness of the underlying health system. This is why it is necessary to assess performance of health systems in enhancing the health status of populations; responding to clients’ non-medical expectations and providing fairness

in financing.10 Knowledge of health economics is necessary in the assessment of how equitably and efficiently a health system performs its functions: stewardship, resource generation, financing, provision of health services.

Concluding remarks In the context of public health, the discipline of economics is critically important for measuring health impact of disease and interventions; evaluating the cause-effect relationship between care-seeking behaviour and the specific attributes of individuals and health systems; estimating the statistical association between patient compliance and

personal as well as intervention-specific attributes. Health economics can also measure inefficient resource use by individual health institutions; guide the choices in public health interventions; assess the macroeconomic relationship between disease, development, poverty, and globalization; and assess health systems performance.

*Dr Kirigia is the Regional Adviser for Health Economics at the Regional Office.

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Sambo LG and Kirig� Murray CJL and Frenk J, A framework for assessing the performance of health systems, Bulletin of WHO, 78(6): 717–731, 2000.

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AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

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Overview of the Strategic Health Economics Plan, 2006–2015 Introduction A number of recent global and regional initiatives on health include the Millennium Development Goals (MDGs),1 the New Partnership for Africa’s Development; the Report of the Commission on Macroeconomics and Health,2 the WHO Regional Committee for Africa resolution on macroeconomics and health; Poverty Reduction Strategy Papers; and the multilateral trade agreements.3 These have served to raise awareness of the important role that health economics plays in health decision-making. Health economics has a valuable role to play in the costing of MDG-related interventions, guiding choices of public health interventions with greatest expected value for money, evaluation and design of sustainable and equitable health financing mechanisms. The fifty-third session of the WHO Regional Committee for Africa adopted a resolution on macroeconomics and health that urges Member States to strengthen health4 economics and public health capacity within the ministries of health and other relevant sectors in order to enhance the effectiveness and efficiency of health investments, and preempt and mitigate negative effects of development projects on public health. In the same resolution, the Committee urged the Regional Director to provide support to regional institutions that train health economists and conduct research in health economics and related fields.

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This article outlines a ten-year strategic plan for strengthening health economics capacities in WHO Member States of the African Region.

Regional strategic plan for health economics Vision The vision of this strategic plan is that by 2015, countries in the African Region will be using health economics principles and evidence to inform policy; advocate, justify and utilize resources efficiently, effectively and equitably within their health sectors to improve the health status of their populations; and achieve the health-related MDGs.

Mission The mission of the regional health economics programmes is to advise, advocate and provide technical support to Member States on the most effective use of economics-based models in building systems, promoting equity and efficiency in resource mobilization, utilization, health financing and comprehensive service delivery. The programmes will employ a country focus and Member State-led approaches in defining specific country priorities in collaboration with other development partners and nongovernmental organizations.

Goal The goal is to evolve a culture for using health economics principles and evidence in policy-making, planning, choice of interventions, resource allocation and utilization to ensure that health benefits are optimised and maximized. The aim also is to reduce health

*Dr Paul-Samson Lusamba-Dikassa

inequalities and inequities in access to health promotion, prevention, curative and rehabilitative interventions within the population.

Guiding principles In order to achieve the above-mentioned goal, the following principles must underpin the process of strengthening health economics capacities in countries: • Multidisciplinarity: It must be multidisciplinary, i.e. involve other disciplines outside health. • Integration into development agenda: It must foster integration of health issues in the development agenda. • Responsiveness to country needs: It must be relevant to the different health needs and problems of each country, i.e. contribute to the formulation and implementation of policies that will support health development.

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UN, United Nations Millennium Development Goals, New York, United Nations, 2000. 2 WHO, Macroeconomics and health: investing in health for economic development, Geneva, World Health Organization, 2001. 3 WHO and WTO. WTO agreements and public health: a joint study by the WHO and the WTO secretariat. Geneva, World Health Organization and World Trade Organization, 2002. 4 WHO/AFRO, Macroeconomics and health: the way forward in the African Region (Resolution AFR/RC53/R1), Brazzaville, World Health Organization, 2001. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

• Efficiency and equity: It must enhance efficient and equitable choice of interventions, allocation and use of all health resources. • Promotion of pro-poor policies: It must ensure that the application of health economics evidence in decision-making enhances poor people’s access to cost-effective interventions. • Bioethics: It must ensure that collection, analysis and interpretation of information obtained from human beings is undertaken in an ethical manner that assures protection of the dignity, integrity and safety of all actual or potential research participants.

Objectives The major objectives of the strategic health economics plan are to: a) Support Member States to develop or strengthen health economics capacity to generate and utilize health economics evidence for decision-making and improvement of health system performance with a view to achieving the health-related MDGs, reducing disease burden and developing long-term pro-poor health development and financing strategies; b) Support countries in monitoring health inequalities and inequities in distribution (by gender, race, social groups, education, income and geographical location), access and utilization of promotive, preventive and curative services; c) Forge regional and international partnerships for promoting, coordinating and funding health economics research and training.

Targets The targets identified for the end of the strategic plan period (2015) are: a) At least 50% of the countries in the Region will have at least one health economist based at the Ministry of Health; b) At least 20% of the countries will AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

have included health economics in the undergraduate and postgraduate curricula for national medical or public health schools and other institutions; c) At least 25% of the countries will have undertaken a statistically representative national study and 50% will have undertaken other studies to monitor the impact of health sector reforms on the functions and goals of health systems; d) At least 15% of the countries will have generated evidence on one or more of the following: cost of health facility-based services; technical and allocative efficiency; equity in resource allocation; trade and health; e) All the regional priority programmes, in line with the MDGs, will have generated evidence on economic impact, economic cost and cost-effectiveness of their interventions; f) At least 50% of the eligible countries will have been supported to formulate (or revise) the health component of poverty reduction strategies; g) At least 50% of the countries will have been supported to develop comprehensive health investment plans; h) At least 25% of these countries will have implemented their comprehensive health investment plans; i) At least 50% of the countries will have institutionalized national health accounts; j) At least 40% of the countries will have developed (or revised) propoor health financing policies; k) The Regional Office will ha ve facilitated the establishment and functioning of three subregional networks of health economists; l) At least three regional health economics centres of excellence will have been designated as WHO collaborating centres.

Strategic thrusts In order to achieve the objectives and targets listed above, the strategic thrusts will be advocacy; country capacity strengthening; support for regional health economics institutions; strengthening of mechanisms and processes which support health economics; technical support to countries; economic evidence generation and dissemination; regional linkages and networking; strengthening of the Regional Office health economics capacity; and resource mobilization.

Implementation Framework The Ministry of Health, with the support of WHO Country Offices, should: a) Undertake a situation analysis of the existing national health economics capacity and estimate the additional number of health economists that need to be trained; b) Include the training of health economists in national policies, plans and budget for development of human resources for health; c) Encourage and sponsor national staff to enrol in health economics certificate, sandwich, diploma and degree (including internet) courses offered by accredited national and international institutions; d) Provide fellowships to appropriate nationals for post-graduate training in regional health economics institutions with a view to creating a local pool of trainers; e) Spearhead the inclusion of a module on health economics in the undergraduate and postgraduate curricula for national medical or public health schools; national universities, schools or departments of economics, and other institutions; f) Compile and maintain a national inventory of health economics research undertaken by various stakeholders in the country; g) Identify, in close collaboration with

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all relevant stakeholders in the country, the priority national health economics research needs; h) Utilize, whenever available, health economists based in the country to undertake health economics research and advise on health economics-related aspects of health systems; i) Create an enabling environment for ensuring retention of health economists within the country.

economic evidence; f) Develop and update databases on regional health economics experts and research; g) Develop a website or web-page on health economics and update it regularly; h) Promote the sharing of health economics expertise between countries;

The Regional Office should:

i) Facilitate the establishment of subregional health economics networks where they do not exist;

a) Facilitate the designation of the main regional health economics centres of excellence as WHO collaborating centres;

j) Organize a biennial conference with subregional health economics networks to share methodologies and research results;

b) Support Member States in soliciting for training grants for nationals to train in regional health economics centres of excellence;

k) Proactively generate and publish relevant regional evidence in regional and international journals to increase awareness of health economics, and take the lead in the establishment of an African journal of health economics.

c) Participate in teaching and cosupervising students in the regional health economics institutions; and provide external examiners, as and when requested by the regional institutions; d) Provide support to regional institutions willing to set up health economics training programmes to ensure standards in curriculum; e) Encourage the regional priority programmes to budget for and undertake studies for generating relevant

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Partnerships for plan implementation At the country level, in the process of identifying appropriate fellowship grantees, it will be necessary for ministries of health to involve national universities, regional health economics centres of excellence and organization(s) providing the fellowships. In addition, it will also be necessary to closely involve all relevant stakeholders in the coun-

try, such as the ministries of finance and planning, private health subsector representatives, national universities, national health research institutions, and potential funding agencies in the process of delineating priority national health economics training and research needs. At the regional level, the work of the Regional Health Economics Programmes will be complemented by the African Health Economics Advisory Committee, the African Advisory Committee on Poverty and Health, and the WHO collaborating centres on health economics. Alliances with international and regional development agencies will be built and nurtured to support the implementation of the strategic health economics plan.

Monitoring and evaluation In order to ascertain progress in the realization of the planned targets, monitoring will be carried out at the end of each year, at both country and regional levels. Detailed evaluation will be carried out after every five years.

*Dr Lusamba-Dikassa is the Director of Programme Management at the Regional Office

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Health development planning in the African Region: a status report Introduction The last century saw the greatest medical advances in history, reflected in healthier populations and rising life expectancy.1 Many of these advances have yet to reach the poorest people in the African Region.2 The underlying causes of many of today’s health problems are well known, and effective key health interventions as well as effective and affordable medicines often exist. However, in most countries in the African Region, potentially effective policies and programmes frequently fail to reach the households and communities that need them the most. This is because of a number of problems related to socio-economic decline, political instability, civil war, lack of good governance, the HIV/ AIDS epidemic, as well as problems related to the provision of goods and services to rural and low income populations. Many countries in the African Region have embarked on health sector reforms in order to improve the health status of their people, particularly those with the greatest needs and expectations. In that context, health development planning has been widely promoted in recent years and is usually linked to national health policy (NHP), the health component of Poverty Reduction Strategy Papers (PRSPs), sector-wide approaches (SWAps) and the Millennium Development Goals (MDGs). The aim is to set clear and implementable priorities for the use of available and potential resources in the most appropriate and cost-effective manner. The growing numbers of actors and health agenda in the health sector have revealed that health development planning should be seen as a response to AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

the need for sound leadership and coordination of the health sector. This is especially crucial at this time of considerable challenges, including very limited resources, and complex and increasing health needs.

*Saidou Pathé BARRY

Health ministries in the majority of countries within the African region have developed or are currently developing their own national health development plans (NHDP). Most of these countries have requested WHO technical support for guidance in the process. **Dr Omer Ayayi Mensah

What is health development planning? Health development planning is a process of setting agreed priorities for the health sector in the light of given resource constraints.3 A health development plan provides the framework within which the NHP and other policies and strategies are implemented, taking into account the vision and strategic orientations defined by the country, as well as global and regional health initiatives. Traditionally, national health development plans have focused on the actions within the public sector ,with little attention to the private sector and others that have influence on health. If, however, the NHDP is intended to cover the whole health system, then it needs to give adequate attention to the actions of both the private sector (including NGOs) and the public.

Health development plan formulation The responsibility of a national health development plan belongs to the Ministry of Health. The plan must be

decisive, targeted, owned and implemented by the national health authorities for the purpose of resolving priority public health problems.4 However, the Ministry of Health alone cannot significantly improve the health status of the population. Thus, the Ministry of Health must analyse the health implications of other sectors and use advocacy and dialogue to influence their actions.

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Anon, Challenges for the new century, Health Action, 23 January –April 1999. 2 There are 46 countries belonging to WHO African region, all except Algeria situated in sub-Saharan Africa. 3 WHO, A guide for the development of national health policies and plans, Brazzaville, World Health Organization, Regional Office for Africa (forthcoming). 4 Health systems reforms in the developing countries: what are the lessons of the past ten years?

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Figure 1: Stages in health development planning Situation Analysis

Formulation Monitoring & Evaluation

Consultation Approval

Dissemination

Implementation

Source: Adapted from WHO AFRO guide for the development of a national health policy and plan.

Process of planning and implementation The socioeconomic and political environments of each individual country can affect both the development and implementation of a national health development plan. When the economy of a country increasingly relies on international financial agencies (which is the case in many African countries), great attention should be given to the conditionalities imposed by donors in order to support the health sector. Experience in the WHO African Region has shown that ministries of health usually create an NHDP through a decentralized (bottom-up) planning process, a centralized (top-down) process or a combination of the two. Each of these processes has its advantages and disadvantages. The decentralized process empowers local bodies and incorporates local priorities and objectives. Though this approach seems complex and time-consuming, it is the preferred process. The centralized process is recommend-

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ed when certain aspects need firm direction such as those related to health financing mechanisms. In the combined approach, there is usually an indicative plan from the centre that guides the lower level of administrative units and within which there is some autonomy to allow flexibility and responsiveness to local needs.3

Situation analysis The formulation of an NHDP can be done in different stages as indicated in Figure 1. Many countries need to make greater efforts to move from focusing on symptoms to emphasizing systems; such thinking encourages enquiry into the underlying root causes of health systems weaknesses. A good situation analysis will (i) analyse the functioning of the different components of the health system5 and its environment; (ii) analyse epidemiological trends; (iii) identify the priority public health problems and the major potential challenges in addressing them and (iv) provide baseline information for future monitoring and evaluation. A situation analysis often considers the socioeconomic and

political environment, health context, health systems, resource constraints and other factors.6 It should also review a country’s strengths, weaknesses, opportunities and threats (SWOTs) to determine health priority issues and challenges.

Formulation The principle that should underline the drafting of the NHDP is that of ensuring its ownership by national authorities and stakeholders. Clear objectives and agreed priorities for the plan as well as the means to achieve them need particular attention given their importance. Therefore, it is essential, after identify-

5

The World health report 2000 defines a health system as” all the activities whose primary purpose is to promote, restore or maintain health.” 6 Strategic health planning: guidelines for developing countries, Nuffield Institute for Health, 2002. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

ing the objectives and strategies, to determine the main actions that have to be taken. Human, financial and material resources necessary for the execution of the plan should be identified as a first stage in the preparation of a budget that will include investment and recurrent costs. In addition, the sources of funds for the prepared budget should be known as well as the available amount, including any gaps, in order to facilitate the mobilization of resources. Countries in the Region have used three methods for writing an NHDP, that is, formulation by an existing planning unit or department within the Ministry of Health, by a team of health people in the ministry of health, and external experts with a specific task to develop the plan in a limited period of time or by consultants. Each of these has its advantages and

disadvantages, particularly in terms of speed of delivery and ownership.

Approval Each country has its own mechanisms for approving their plans. However, in all countries there are likely to be some approval requirements within the ministries of health and others at central and multisectoral level.

Dissemination To obtain wide acceptance of the NHDP, countries should develop a dissemination strategy as part of the development plan. They should use various dissemination methods, going beyond the traditional public health methods which are likely to be insufficient.

Implementation The final NHDP should take into account and harmonize the plans from the different levels of the health system (national, regional and district levels) including specific health institutions. An NHDP is of little use if not implemented, and yet in the African Region many NHDP remain unfulfilled aspirations. Thus, it is important that very explicit links are made between the strategic plan and operational plans and budgets as the mechanisms for implementation. It is important to link the NHDP to the Medium-Term Expenditure Framework (MTEF) and operational plans to annual budgets for implementation purposes. Funding for NHDP can be sourced from the Global Fund to Fight AIDS, Tuberculosis and Malaria , the Global Alliance for Vac-

Figure 2: NHDP content

Background and achievements

Situation Analysis Socioeconomic context, health status of the population, health services provision and utilization, key issues and challenges

Resource Requirements Human, physical infrastructure, materials and supplies, financial resources and management, communication, information

Strategic Health Priorities Strategic orientations, specific objectives, main actions, indicators and targets

Finance plan Estimated cost of the strategic orientations; assessment of available and projected funds, determination of financing gap; ways of closing the financing gap

Implementation Framework Log frame with goals, strategic orientations, objectives, verifiable indicators and targets and means of verification in some tabular form as well as actors, their roles and relationship

Monitoring and Evaluations Annexes

Proposed mechanisms for monitoring and evaluation, costing the monitoring and evaluation component and plan

Source: Adapted from WHO AFRO guide for the development of a national health policy and plan. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

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Figure 3: Status of NHDP in the African Region

Figure 4: Formulation of NHDP in the African Region

cines and Immunization, and the Highly Indebted Poor Country Initiative.

while in others it is linked to SWAps, PRSPs and MDGs.

Monitoring and evaluation

NHDPs in many countries were developed for a five -year period (20 out of 32 countries for which information is available at the Regional Office (Figure 3). Previously, some countries had longterm plans covering ten years (eight out of 32 countries). These were supplemented by shorter prepared plans with greater detail. The shorter 3- or 5-years plans were linked to the MTEF and were complemented by shorter operational plans and annual budgets for implementation purposes. Countries are showing growing interest in the development of their NHDP. For example, 35% of existing plans were written between 2000 and 2003 (Figure 4). However, many countries have yet to update their plans.

While designing the NHDP, it is important to consider how its progress will be measured and its achievements evaluated, indicating the needs for clear indicators for both the NHDP and operational plans. Monitoring and evaluation will indicate progress and constraints encountered during the implementation phase and help to address the underpinning issues.

Consultation It is important that sufficient attention be given to the process of consultation during the formulation of the NHDP. Communities, parliamentarians, political parties, key ministries, health professionals, private sector health care providers and others should be consulted in the early stages for views on priorities and strategies.

Content The content of existing national health plans varies from country to country. The most common elements are featured in Figure 2.

Timeframe The timeframe varies from country to country and is sometimes influenced by donor interests. In some countries, the NHDP is a continuation of the process for national health policy formulation,

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The role of WHO in health development planning The WHO Regional Office for Africa has produced a guide for the development of National Health Policy and Plan. WHO will make this tool available to countries for use in order to enable them to undertake this important process and to assess their own planning systems which they can strengthen, as appropriate. However, it should be stressed that there is no single blueprint for creating a NHDP. Each country has its particular environment in which the planning

process takes place and specific requirements needed for different solutions for health planning. This guide, therefore, is intended to highlight the main issues that should be kept in mind while formulating an NHDP. WHO will continue to provide technical support and build capacity within WHO Country Offices and Member States to develop plans which are realistic in their aspirations. WHO will also advocate for mobilization of more resources from both countries and partners for the implementation of existing plans.

Conclusion The National Health Development Plan should be seen as an opportunity for placing health at the centre of development at country level, and for opening up the dialogue between ministries of health and partners, including private sector and civil society, among others, in order to maximize benefits from their contribution to achieve better health outcomes in the African Region.

*Dr Pathé BARRY is the Regional Adviser for National Health Systems at the Regional Office **Dr Mensah is with the Programme Planning and Evaluation Unit at the Regional Office AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Health financing in the WHO African Region Introduction Mills and Ranson define health financing as the raising or collection of revenue to pay for the operation of the health system1. It has three sub-functions: revenue collection, pooling of resources, and purchasing of interventions.2 WHO3 describes revenue collection as the process through which the health system receives money primarily from households and organizations or companies (firms), as well as donors. There are two broad sources of health financing: public sources and private sources. Public sources include: general tax revenues (from personal income tax, taxes on domestic business transactions and profits, taxes on imports and exports, and property taxes); indirect taxes incorporated into the selling price of a good or service (e.g. sales and value added taxes and excise duties on tobacco products and alcoholic drinks); taxes on lotteries and betting; domestic and international deficit financing (issuance of debt certificates or bonds and loans from bilateral and multilateral agencies); external grants (includes charitable donations by foreign governments or organizations); and social insurance (mandatory insurance payments by employers and employees).4 Private sources include: households (direct out-of-pocket payments by a health services consumer to the provider); employers (firms paying for or directly providing health services for their employees); private insurance (voluntary payments to private insurance companies in return for coverage of pre-specified health service costs); donations (charitable contributions made in cash or kind); and voluntary organizations or non-governmental organizations.5 WHO defines pooling as “the accumulation and management of revenues in AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

such a way as to ensure that the risk of having to pay for health care is borne by all the members of the pool (i.e. the financial risk is shared) and not by each contributor individually (as is the case with out of pocket payments)”.6

*Dr Rufaro Chatora

Purchasing is “the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health interventions”.7 Provider payment mechanisms include: line item budget; global budget; capitation; diagnostic related payment; feefor-services.

expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. The analysis was done using EXCEL spreadsheet.

The performance of a health financing system depends on the level of prepayment; the degree of spreading of risk; the extent to which the poor are subsidized; and strategic purchasing (active leveraging of provider payments mechanisms to optimise overall health system performance).8

Percentage of GDP spent on health: Four countries spent less than 5% of GDP on their health; 25 countries spent between 5% and 10% of their budget; and 13 countries spent between 11% and 14 % of their budget on health (Figure 1).

We present below an analysis of the patterns of health financing in the WHO African Region.

Methods The national health accounts data on the 46 WHO Member States in the African Region were obtained from The world health report 2004.9 It consisted of information on: levels of per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket

Results

Per capita total expenditure on health: Total expenditure on health per person per year is less than US$ 10 in 12 coun-

References 1 Mills AJ, Ranson MK, The design of health systems. In: Merson MH, Black RE and Mills AJ (editors). International public health: Diseases, programmes, systems, and policies. Gaithersburg, Aspen Publishers, Inc, 2001. 2 WHO, The world health report 2000. Health systems: improving performance, Geneva, WHO, 2000. 3 Ibid. 4 Mills AJ, Ranson MK, The design of health systems. In: Merson MH, Black RE and Mills AJ (editors). International public health: Diseases, programmes, systems, and policies. Gaithersburg, Aspen Publishers, Inc, 2001. WHO, The world health report 2000. Health systems: improving performance, Geneva, WHO, 2000. 5 Ibid 6 WHO, The world health report 2000. Health systems: improving performance, Geneva, WHO, 2000. 7 Ibid. 8 Ibid. 9 WHO, The world health report 2004, Geneva, World Health Organization, 2004.

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Figure 1: Total expenditure on health as a % of GDP (in 2001)

tries; between US$ 10 and US$ 29 in 20 countries; over US$30 in 13 countries (Figure 2). Per capita government expenditure on health: Government expenditure per person per year is between US$ 1 and US$ 9 in 30 countries; US$ 10 and US$ 28 in seven countries; and US$ 46 and US$ 307 in nine countries.

Figure 2: Levels of per capita total expenditure on health (in 2001)

Sources of funding Government financing: General government expenditure on health includes health expenditure at all levels (and ministries) of government, including the expenditure of public corporations. Over 51% of the total expenditure on health in 30 countries is from government sources (Figure 3). Government is an important source of health financing, seldom paying less than 20% of the total health expenditure, and sometimes over 80%.

Figure 3: General government expenditure on health as a percentage of total expenditure on health, 2001

% of government expenditure on health Figure 4: Private expenditure on health as a % of total expenditure on health

Private financing: Private financing for health comes from personal outof-pocket payments made directly to various providers (e.g. private practitioners, private pharmacists, traditional healers), prepayments to community financing schemes (e.g. Bamako initiative), private insurance and indirect payments for health services by employers (firms) and local charitable groups. Figure 4 depicts private spending on health as a percentage of the total expenditure on health. In 40 countries (i.e. 87%) private spending constituted over 30% of the total expenditure on health. In 16 countries, over 50% of the total expenditure on health was made up of private spending. Out-of-pocket payments: The contribution of out-of-pocket expenditures into the private health expenditure is quite significant in most countries of the Region. In 19 countries, out-of-pocket expenditures constitute 100% of the private health expenditure (Figure 5). In the remaining countries, out-ofpocket contribution varies from 18.7% to 99.9%. Health insurance: In principle, health insurance consists of social insurance

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AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

(which is compulsory), private insurance (which is voluntary), and employer-based insurance (eligibility dependent on employment status). Out of 39 countries whose data were available, 23 of them had no health insurance. However, in the remaining 16 countries there were health insurance plans that made varied contributions to the private health expenditure (Figure 6). It was only in two countries (Namibia and South Africa) where health insurance contributed over 72% of the private health expenditure. External financing: This consists mainly of loans and grants from multilateral and bilateral aid donors and nongovernmental organizations. As shown in Figure 7, all countries in the Region receive some external funding for health. However, the magnitude of external funding on health as a percentage of total expenditure on health varies a lot from country to country. A total of 23 countries obtained over 20% of their total expenditure on health from external sources; 12 of these financed over 30% of their total expenditure on health using external financing.

Discussion Percentage of GDP spent on health: In the Region, 65% of the countries allocated less than 5% of their gross domestic product (GDP) to health. Given the importance of health in human capital development, and hence, in economic growth and development, one would have expected countries to invest a greater share of GDP to health development. The size of GDP allocated to health sector depends mainly on the priority attached to health development and on the rate of economic growth. If these two factors are low, the likelihood is that the percentage of GDP allocated to health would also be low, and vice versa. National budget allocated to health: Heads of State of African countries made a commitment in Abuja to allocate at least 15% of their annual budgets to the health sector.10 By end of 2001, only four countries spent 15% and above of their budgets on health. This AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Figure 5: Out-of-pocket spending as a % of private health expenditure (in 2001)

Figure 6: Prepaid plans as a % of private health expenditure

Figure 7: External funding on health as a % of total expenditure on health

means that 42 countries spent less than 15% of their national budgets on health and will need to take appropriate steps to honour the commitment given by their respective Heads of State. Per capita government expenditure on health: Thirty seven percent of the governments in the Region spend less than US$30 per person per year on health. The WHO Commission for Macroeconomics and Health report estimates that a

10

AU, Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Addis Ababa, Organization of African Unity, 2000.

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minimum government expenditure of US$ 34 per person per year will be required to provide an essential package of public health interventions in order to achieve both the relevant MDGs and NEPAD targets.11 Thus, those governments currently spending less than US$ 34 on health per capita per year will need to increase their budgetary allocations to reach the recommended minimum health spending. Government Budget Financing: Over 51% of the total expenditure on health in 30 countries of the Region came from government sources. Akin et al has criticized this source of funding as inefficient and inequitable.12 However, given that about 50% of the people in the Region live below the poverty line of US$1 per day, there is obviously a role for government financing as a force for equity in sharing health care costs and for government provision of services to improve equity in access for the poor. Of course, there is need to monitor the efficiency in use of funds from government and the efficiency in production of services. Private financing: In forty countries, private spending constituted over 30% of the total expenditure on health, while in 16 others, it was over 50%. Out-ofpocket payments constitute the main component of private health expenditure in most countries of the Region. Published evidence indicates that user fees: (i) may not necessarily have the theoretically expected efficiency effects on cost containment (mainly due to information asymmetry in the patient-clinician relationship); (ii) may not generate substantial net revenue for the health sector; (iii) may not be acceptable to consumers due to poor perceptions of the quality of services (especially in public facilities) and inability to pay; (iv) have adverse effects on demand and utilization of health services for the poor. Thus, although private spending is currently a significant source of health financing it is inequitable, and may have adverse effects on health status of the most vulnerable groups in society. Health insurance: Generally, the role of

16

private and compulsory health insurance in the Region has been quite limited due to wide spread poverty, and a high proportion of the population working in the informal sector. However, due to inequities related to out-of-pocket payments and the need for sustainable funding for the health sector, there is growing interest among countries on the feasibility of introducing social health insurance.13 Efforts to introduce social health insurance may face a number of challenges: (i) lukewarm support from Bretton Woods institutions; (ii) vulnerability to changes in levels of unemployment, e.g. if unemployment increases and real wages decrease the real level of resources for health insurance decreases; (iii) administrative costs of setting and running social health insurance may be very high; (iv) weak administrative capacity and financial control systems; and (v) moral hazard (abuse of insurance benefits without bearing financial consequences of one’s behaviour).14 External funding: A total of 23 countries obtained over 20% of their total expenditure on health from external sources; 12 of these financed over 30% of their total expenditure on health using external financing. So far, external aid is unpredictable, unstable and uncoordinated.15 In order to increase aid effectiveness: (i) it should be 100% untied aid; (ii) 90% should be allocated to the poorest countries; (iii) partners should shift from project to poverty reduction budget support; (iv) partners should align themselves behind national health development policies and plans to ensure country ownership of health development process; (v) partners should aim for 100% debt relief for low income countries; (vi) partners should review their lending policies and practise on aid conditionality to reduce inefficient bureaucracy and attendant administrative costs; (vii) adopt an international health worker recruitment code to stem the tide of brain-drain of human resources for health to developed countries. The CMH calls upon rich countries to allocate at least 0.7% of their gross national product to developing countries. However, none of the rich countries has met that target; and they need

to implement that recommendation to enable low income countries realize the MDGs.

Conclusion The countries that do not have health financing policies need to develop them to protect populations (especially the vulnerable groups) from catastrophic expenditures. For quite sometime to come, countries will continue having a mix of sources of funding for the health sector. However, the important thing would be to ensure that there are functional safety nets for the poor. As the countries contemplate reforming their health financing systems, it will be important to prospectively evaluate them against a number of criterion: level and reliability of expected revenue; incentives to consumers and providers of care; technical, allocative and administrative efficiency (including effects on clinical quality of care); equity in distribution of benefits and costs; expected health impact; and acceptability by consumers, politicians, medical and nursing associations, employer associations and trade unions.16

*Dr Chatora, formerly Director Division of Health Systems and Services Development at the Regional Office, is now Director of the Division of Noncommunicable Diseases at the Regional Office.

11

WHO, Macroeconomics and health: Investing in health for economic development, Geneva, World Health Organization, 2001. 12 Akin JS, Birdsall N, de Ferranti D., Financing health services in developing countries: an agenda for reform, Washington, DC: World Bank, 1987. 13 WHO. Sustainable health financing, universal coverage and social health insurance, EB115.R13, Geneva, World Health Organization, 2005. 14 Kirigia JM et al, Determinants of health insurance ownership among S. African women, BMC Health Services Research, 2005, 5:17. 15 UK Government, The UK’s contribution to achievement of the MDGs, London: UK Government, 2005. 16 WHO, Evaluation of recent changes in the financing of health services, Geneva, World Health Organization, 1993. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Macroeconomics and health: the way forward Introduction Improved health is not only an end in itself, but an essential means of reducing poverty and achieving sustained economic growth. Before the release of the Commission on Macroeconomics and Health (CMH) Report, economic wealth was taken as the driver of health. “As people get wealthier, they will get healthier”, it was thought. After the CMH evidence, health is being understood as the driver of poverty reduction. More arguments are coming to the fore that a well-planned strategy for health investments will accelerate social and economic growth. Good health is a necessary condition for development. Building upon the CMH Report, a programme for coordination of macroeconomics and health was created. The programme has three components: improving health outcomes, especially among poor people; strengthening commitments to increased financial investments in health; and minimizing non-financial constraints to the absorption of greater investments. These components provide a context for a macroeconomics and multisectoral approach to strategic health investments. This article reflects on the perspective of macroeconomics and health and the way forward in the WHO African Region. It gives some background to macroeconomics and health, suggests the way forward by outlining the necessary phases in a successful plan of action and concludes with some brief suggestions for implementation, of the CMH recommendations.

Background The World Health Organization established a Commission on Macroeconomics and Health (CMH) in January 2000, to study the links between inAFRICAN HEALTH MONITOR JANUARY – JUNE 2005

creased investments in health, economic development and poverty reduction. The Commission’s findings demonstrated that judicious investments in health, with health understood in a broad sense, can help improve the economic growth of developing countries. The report points out that ill-health contributes significantly to poverty and low economic growth; that a few conditions account for the high proportion of ill-health and premature deaths, and that a substantial expansion of coverage of cost-effective interventions in priority health problems could potentially save millions of lives per year in the Region. To achieve this, countries are recommended to have “close-to-client” systems and to scale up cost-effective public health interventions, targeting especially the poor. Current levels of spending, however, are too low to be able to scale up cost-effective interventions. Though opportunities exist to improve current resource availability within health systems, a major financing gap will still need to be filled from external sources. The report also points out that currently very little research is being done on the health problems of the poor. It therefore recommends strengthening of national research institutions to generate information needed to improve health systems and delivery of health services. It also emphases that there are several determinants of health, and these are not only confined to the health sector. The recommendation is therefore that investments in healthrelated sectors must also be increased. The report of CMH recommends enhanced political commitment, at both national and international levels, to increased investments for scaling up the delivery of essential health interventions using close-to-client health systems.

*Dr Chris Mwikisa

A way forward The WHO Regional Office for Africa has developed a generic plan of action format for the implementation of the CMH action agenda. The format comprises three phases. Given that countries are at different levels of development and implementation of plans, the phases are to be adopted by each country according to its circumstances. The three phases are: • Consensus-building and setting up appropriate institutional arrangements • Developing health investment plans and mobilizing resources • Implementation,monitoring,evaluation and reporting.

Consensus-and institutionbuilding Phase one, which is anticipated to last for six months, has two steps and two main objectives. The first step aims to disseminate the findings and recommendations of CMH, with the objective of building consensus on their relevance at the country level. Through meetings of key stakeholders, ministries of health are to disseminate the findings and recommendations of the CMH Report and build consensus on its relevance to the national health situation. This would potentially begin a process that would build greater political and financial commitment to the health and related sectors such as water, sanitation and education. The major expected outcomes are a consensus, a national

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action agenda and commitment by all stakeholders to support governments in implementation. The objective of the second step is to establish institutional arrangements for facilitating the implementation of a national agenda. The outcome of this step will be the establishment of two committees, a national steering committee and a technical committee, which will be located in an institution deemed by each country to be the most appropriate. Given the existence in many countries of numerous committees, a possible alternative is to identify an already existing committee that is best placed to take on additional responsibilities. With government, guidance the steering committee would lead the task of scaling up priority health and healthrelated interventions, and advocate at national and international levels for increased investments in health.

Health investment plans and resources Phase two is estimated to take 18 months. The objectives are mainly to conduct a health and health-related situation analysis; develop multi-year strategic investment plans to extend coverage of essential health and healthrelated services; develop scenarios for financing gaps, taking into account issues of equity, burden and sustainability; revise the health and health-related sectoral development plans; revise the relevant components of poverty reduction strategy papers (PRSPs) estimate resource requirements and gaps; design implementation plans; and mobilize resources. These objectives are to be

achieved through analysis and strategy building, filling expenditure gaps, and revising the health and health-related sectoral development plans as well as the relevant components of PRSs Plans. To develop strategies, countries will need to undertake analyses of the national health situation (including risk factors), health policies, health system performance (goals and functions), national health accounts (or health expenditure review) and macroeconomic (including poverty) indicators. The expected outcomes will include: • health and health-related sector situation analyses; • a set of priority national health problems; • a package of cost-effective “essential public health interventions” for addressing problems; • current levels of coverage for various essential interventions; • target coverage of individual essential health interventions; • cost of scaling coverage of essential interventions to desired targets; • an estimate of the current level of spending on the essential interventions. · When investment plans have been drawn up, they should be incorporated in health and health-related sector development plans and the relevant components of PRS plans. This should be done by ministries and agencies with primary responsibility for specific components of the plans. Countries will determine the expenditure gaps and indicate how they will be financed by mobilizing both domestic and international resources.

Implementation The last phase of the proposed way forward is implementation of the multiyear strategic plan. The phase progresses to monitoring, evaluation and reporting. The lessons emerging from monitoring and evaluation will form a basis for revising the multi-year plans.

Conclusion To successfully implement the recommendations of the CMH Report, countries need to improve the capacity of ministries of health for advocating and negotiating with other sectors and partners. Country-specific studies showing the linkages between health and economic development should be undertaken and form the basis of advocating for more resources. Health should not be taken as a prerogative of the ministries of health alone. Investments in other sectors such as education, water and sanitation can contribute significantly to the attainment of the health goals. Perhaps the most important requirement for successful implementation is commitment and political will by the countries and international community to allocate the necessary resources for scaling up costeffective interventions.

*Dr Mwikisa is the Director of Healthy Environments and Sustainable Development at the Regional office

References Bloom D and Canning D, The health and wealth of nations, Science 287, 1209, 2000. Bloom D and Canning, The health and wealth of Africa. Paper commissioned by World Health Organization, Regional Office for Africa, Brazzaville, Congo, 2003. WHO, Macroeconomics and health: investing in health for economic development, Geneva, World Health Organization, 2001. WHO, Final report of the fifty-third session of the WHO Regional Committee for Africa, Brazzaville, World Health Organization, Regional Office for Africa, 2003.

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AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Using the Long-term Perspectives Approach in National Health Strategic Planning Introduction Most decisions made by policy makers and senior managers in the health sector concern actions and events which have implications on the future of the health system or which will take place in the future. These decisions require a vision of a future health situation and health status that fulfills the aspirations of all, and that is coherent and motivating enough for all key stakeholders to participate in its achievement.. Without a national health vision for the 21st Century and an effective well-costed strategy to achieve it, countries in the African region will not effectively and rapidly achieve their health goals including the Millennium Development Goals (MDGs). Since the future remains unknown and highly uncertain due to the rapid and dynamic changes characterizing the 21st Century, it is critical for national authorities and health sector planners to attempt an analysis of the future health situation before offering any solutions to current (and future) health challenges. Setting proper long-tern and medium term health goals as well as appropriate contingency plans in preparation for any unforeseen circumstances will determine which countries will do better in their efforts to achieve the MDGs . This will avoid rush decisions, mistakes and a “fire-fighting” approach to sudden or unforeseen developments in the external environment which require adequate lead planning time if they have to be tackled effectively. The long-term health development (LHD) approach has three basic elements: a strategic situation analysis to determine what is happening in the health sector; a futures analysis to AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

determine what could likely happen and to derive a vision for health development; and creation of a sustainable long-term strategy and policy for health development.

Strategic analysis of the current health situation It is important to systematically collect and analyze strategic information for building scenarios of health development in order to derive a proper health vision and the strategic plan for its achievement. One tool used to collect such information is the Strategic Intelligence Matrix (SIM)1. National brainstorming sessions of key health stakeholders are organized to fill in the matrix focusing on information abbreviated as F.A.C.T.S. – S.W.O.T. meaning: F for Future-bearing event (an event whose impact on health issues will be felt for a long time to come); A for Actor (a key player/stakeholder or group whose actions/motives have a significant effect on the health issues at stake); C or Critical uncertainty (an event, phenomenon, outcome, trend etc. whose nature, future direction, magnitude or effects are uncertain or unknown); T for Trend (manifestation of a phenomenon across different timeframes from past, present, to future as demonstrated by the behaviour or direction of a particular measure or indicator); S for Strategies (courses of action being pursued to deal with the issue – including their effects);

*Dr Anthony Mawaya

S for Strengths (strong or positive aspects/characteristics inherent in the country which policy-makers have the power to manipulate to the advantage of health); W for Weaknesses (weak or negative aspects/characteristics inherent in the country which policy-makers have the power to minimize to the advantage of health); O for Opportunities (positive aspects in the external environment which are beyond the direct control of policymakers but which can be leveraged for health development); T for Threats (negative aspects in the external environment which are beyond the direct control of policymakers but which need to be mitigated in the interest of health development). Since health status and health development is affected by economic, social, political, environmental, cultural and technological factors, it is important to thoroughly search for the FACTSSWOT information in all these six domains focusing only on the health determinants under each domain. Typically, the process used is called Environmental scanning – which identifies ex-

1

Source: Ben Caiquo and O. Adesida (1994) ‘Gathering Information for National Development Strategy’ Paper prepared for African Futures’ Scenarios Training Workshop, Franceville, Gabon. Organised by the UNDP/African Futures Project.

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Figure 1: Strategic Intelligence Matrix (SIM) Issue/Theme: (e.g. stopping brain drain of health workers) Domains

Strategies F

A

C

T

Past

Present

S

W

O

T

Political Economic Social Cultural Environmental Technological

ternal threats, opportunities, emerging issues and extra information critical for scenarios building, designing the country’s national health vision and strategy and reviewing whenever necessary.

Strategic analysis of a country’s future health development Health policies and plans are proposed interventions to be implemented in the future. They should therefore be based on a thorough analysis of the most likely health future situation in the country and the aspirations of all the citizens . Scenarios are just one among many tools used to conduct a strategic analysis of the future health situation by making creative use of the information collected through the SIM. They are logically consistent but different and credible stories of what could likely happen in the future. Scenarios show how the future could unfold2 and, as stories, they are largely qualitative and rely on quantitative data to strengthen the evidence and argumentation through projections, extrapolation etc. Scenarios are NOT predictions nor are they forecasts because the future is too uncertain to be predicted or forecasted. Each story inter-weaves the range of key uncertainties in the six domains of

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the SIM in a coherent, plausible manner exploring new and challenging ways in which the elements in the SIM could possibly combine to create a desirable or undesirable future health situation. The group of experienced health stakeholders from all sectors and levels of society constructing the scenarios elaborate these stories using the “What if…” to show the likely decisions of various key players and their consequences on health status and health development as the future unfolds. In this way, the planners can explore possible conflict situations, problems, emerging issues and the actions that could be taken to lead the country into one health status or the other. Using scenarios is like rehearsing the future in advance, thus living in it conceptually before being there in reality. By recognizing the warning signs and reviewing what is likely to happen, the planning team can plan to avoid surprises and adapt to act more appropriately. The scenarios convey powerful messages to all concerned stakeholders allowing them to communicate, learn and plan together for a more positive future in an uncertain and rapidly changing health environment. Such planning is

done with an understanding of the total health system and the cross-impacts of actions and events between the seven domains of the SIM - opening the mind, challenging conventional thinking, and stimulating strategic thoughts and actions to be considered for a better health future. Typically, at a minimum, there should be at least three scenarios – the worst, the best and a middle-of-theroad scenario - in order to learn the best lessons for creating a realistic vision and strategy. Each scenario will have its moral or lesson that can be interpreted into policy and strategic implications and the actions that could be taken given the said policy and strategic lessons. These actions will have to be woven into the overall final strategy for achieving the health vision – including the contingencies that need to be considered in case the various scenarios begin to manifest themselves. Once the scenarios are constructed and their lessons drawn, the vision of health for the country can then be crafted.

2

WHO-AFRO, Health Futures: Scenarios based health development guidelines, Harare, 2000, p.22 AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

The national health vision The health vision for a country is an expression of the shared long-term goals for health development. The vision, as a desired picture of the future that all key stakeholders in the country aspire to have, will guide all national health development plans, policies and strategies aimed at health development in the country. It is the guiding light for all actions, and provides the spark that will ignite the energies of all stakeholders and empower them to take unified action to create the best possible health status of the country’s inhabitants. In most cases, the vision is an attempt to avoid the worst scenarios and get the best scenario into focus. Thus, in creating the vision, it is important first to review the scenarios and information contained in the SIM, to learn what is the most desirable health system to create the best health status as seen by all the stakeholders. These lessons will assist in understanding all stakeholders’ aspirations of the best possible health future for the country. These ideas, aspirations and lessons of what is most desirable become the key elements or ingredients in crafting the Vision Statement. This statement, besides containing the grand aspirations and goals of the stakeholders, also alludes to a broad approach for its realization. It is this broad allusion to how the vision will be achieved which gives the platform for developing a more detailed strategic plan and appropriate policies for health development. The health vision and strategy should be presented to the wider society for comment and inputs through various media before being finalized.

What should be done to realize a country’s health vision? A national health development strategy has to be put in place to achieve the vision and has to be supported by appropriate and relevant health policies and legislation informed by the goals and aspirations contained in the vision. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Methods and approaches to strategic planning are used to complete this stage which involves marrying the goals and aspirations of the vision for health with information from the SIM. To begin with, the vision as a composite set of health goals and aspirations, is broken down into its specific themes for which specific interventions or strategies can be proposed. At this stage, all the information collected so far from the previous stages, including the SIM (such as the SWOT, results of past and present strategies, trends, etc.) and the scenarios, is collated and used to suggest the interventions. For example, the “strengths” in the economic and political domains can be deployed to mobilize resources domestically and internationally for health systems development to achieve the vision. Those elements listed as “weaknesses” can be eliminated using the strengths or opportunities identified earlier, since weaknesses fall under the control of policy makers. The scenarios are also strategic in that contingency plans/actions can be proposed and their lessons taken into account when proposing the strategies and policies to deal with specific aspects of health development. At the end of this exercise, each theme/ issue in the vision will have an associated set of proposed interventions to achieve the desired status in the short, medium-term to long-term3. The final overall strategy should be assessed for internal consistency, compatibility with its external environment, appropriateness in light of resources, degree of risk, effectiveness, and flexibility4. This will indicate the need for policy i.e. the guiding principles, values, norms and a framework that will underpin the strategy implementation process and keep it focused in one direction – that of achieving the vision. Health policy will guide decision-makers and strategy implementers how they will handle any issues including emerging ethical questions or other matters likely to be encountered during implementation of the strategy. Some of these matters may even require legislation to ensure stronger incentive for compliance from all concerned actors.

Implementation, monitoring and review This strategy is put into action through operational plans showing who would do what when and how to achieve which short, medium and long-term objectives. An appropriate organizational structure is then created for implementing the strategy in line with the health vision. This may involve reviewing existing structures, budgets and institutional arrangements to ensure their alignment with the strategy. Constant monitoring of processes and outcomes is essential in the context of a strategic ‘learning” approach to health development and management where goals, strategies, through continuous environmental scanning lead to strategic revisions of strategy and policy to ensure they are always in line with the vision.

Where we are with the LHD approach in Africa The LHD approach has already been accepted by some WHO member countries in the African Region as the method for elaborating national health strategic plans and policies based on a widely shared national health vision. The LHD Programme of the WHO Regional Office for Africa was conceived to support African countries in their efforts to develop and manage national health development plans and policies in a new and most appropriate way for the dynamic and rapidly changing world of the 21st Century. The Programme encourages long-term strategic thinking and planning to solve the health problems besetting African

3

The medium to short-term plans can then be considered in the context of the country’s poverty reduction strategies such as PRSPs as well as the Medium Term Expenditure Frameworks (MTEFs). 4 For example, how best the developed strategy fits into on-going national initiatives strategies such as the poverty reduction strategies (PRSPs) and the country’s national investment plans as reflected in the medium–term expenditure framework (MTEFs).

21

countries in the most sustainable manner and within the long-term context of the MDGs and beyond. Since the Programme’s creation in 2000, regional sensitization workshops for Anglophone and Francophone countries have been conducted, followed by national ones in several countries. Countries now seek technical assistance to develop their health policies and plans using the LHD approach at the national, sectoral and sub-sectoral levels. As a result, regional and national health policy and plan guidelines for the WHO African Region incorporate aspects of the LHD approach. However, this new approach is still establishing itself as awareness of its

22

usefulness grows. The challenge remains how to meet this growing need and interest amidst limited financial and human resources for the Region in this field. The full LHD process can also appear to be a long and elaborate process that takes patience and concetration due to its comprehensive nature, but the results can be quite mind-opening and essential for strategic planning and policy. Part of the strategy to meet these challenges is to publish shorter user-guides focusing on specific aspects and phases of the approach. These can be used by any interested parties for different planning and policy elaboration needs apart from using the full LHD approach. For example, shorter and simpler guides and training manuals should be produced for strategic

situation analyses using scenarios and other futures analytical tools as well as for vision and strategy formulation. As for implementation, monitoring and evaluation, a guide and training manual on how a country can be an effective “learning” entity with regard to national health development would be most useful in guiding current and implementation health policies and plans.

* Dr Mawaya is the Regional Adviser for Long-term Health Development at the Regional Office

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Poverty Reduction Strategy Papers: An Overview of Health Components Introduction Poverty Reduction Strategy Papers (PRSPs) are documents prepared by national governments in poor countries through a participatory process involving civil society and development partners, including the World Bank (WB) and the International Monetary Fund (IMF). They describe a country’s macroeconomic and social policies for promoting growth and reducing poverty. The World Summit on Social Development (WSSD) 2015 Agenda, endorsed by the highly indebted poor countries (HIPC)PRSP process, supported an ambitious development programme focused on improving social indicators–education, health, water, sanitation. Each country is invited to formalize its commitment to this agenda by preparing a PRSP to be submitted to the Boards of the IMF and World Bank. The WSSD 2015 Agenda was turned into the Millennium Development Goals (MDGs), aiming to halve poverty between 1995 and 2015, with eight specific goals, 18 targets, and 48 indicators. The MDGs give prominence to health: four out of the eight goals, nine out of the 18 targets spread over six of the goals, and 18 out of the 48 indicators directly relate to health sector. The WHO Commission on Macroeconomics and Health (CMH), set up in 1998 released a landmark report in 2001 detailing the negative effects of the high disease burden on economic development, especially in least developed countries (LDCs). The report made strong recommendations for scaling up domestic and international finances to tackle illhealth in poor countries, most of which are in Africa. There are no set guidelines or rules to write Poverty Reduction Strategies AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

(PRSs) or PRSPs that give health the prominence it receives in the MDGs. However, there is an obvious advantage in learning from what has been attempted. This article reviews the approaches proposed or used to assist countries in scaling up the health component of PRSs, including PRSPs, i.e., ensuring that the health of the poor is given prominence through analytical work that leads to pro-poor policies, actions and expenditures. These approaches largely address the question, “What is the basic relationships between poverty and health, nutrition and poverty, and how do they influence one other?”

* Dr Benjamin Nganda

poverty reduction activities. The health sector analysis helps iPRSP authors base their policy recommendations on sound empirical findings. It recommends the analysis of available data to assess the health outcomes of the poor at country level, analyse the interactions between poverty and health, revisit and revise the core set of packages to ensure that diseases affecting the poor are adequately included and prioritized for sustained funding; assess the coverage of the poor with the key interventions selected; and identify gaps in serving the poor and providing these services.

A World Bank approach The World Bank and the IMF, in response to criticism of their structural adjustment programmes (which left many low income country economies in shambles and with increased poverty burdens), introduced a new framework that sought to enhance the poverty impact of country actions and development assistance. The framework focused on a long-term operational approach to poverty reduction and comprehensive development. The World Bank prepared a document to help those working on the health component of the PRSP. It suggested five functions and activities to consider: a discussion of poverty and health; a discussion of “Best Buys”, health sector analysis, building blocks for the full PRSP, and a checklist for interim PRSP (iPRSP) authors and reviewers to ensure that new investments occur in areas that actually reach the poor. The document outlines an analysis of the interaction between poverty and health and summarizes the arguments for investment in health as critical

A logical framework, summarized by four broad questions that lend themselves to the choice of analytical and participatory activities is suggested: • What are the health and nutritional conditions for the poor and how do they compare with those of the better off? Focuses policy and resources on the epidemiological needs of the poor. • Why do poor households and communities suffer more than the better off and what are the barriers faced? Recognizes that poverty is a household and community characteristic

1

World Bank, ‘Rapid Guidelines For Integrating Health Nutrition and Population Issues in Interim Poverty Reduction Strategy Papers of Low-Income Countries, New York, World Bank, 2000. See the document at: http://www.worldbank.org/poverty/strategies/ chapters/health/hnpguide.pdf

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and that individual actions are critical in the improvements of health and nutritional outcomes. • How does the health sector fail the poor and the socially vulnerable? Leads to policy changes within the health sector that would improve the interface between the poor and the health sector as well as improve the advocacy role of ministries of health. • What set of public policies can be delivered to improve the equity performance of the health sector? Prioritizes the selection of interventions. More recently, the Bank has compiled the PRSP Sourcebook which provides guidance both on process aspects of building a poverty reduction strategy, and on practical aspects, such as poverty diagnostics, specific sectoral challenges with respect to poverty reduction objectives, etc., It can be found on the World Bank website.

WHO approaches In recognition of the prominence given to health in the MDGs, WHO initiated a programme of work to systematically monitor the place of health in PRSPs (see the WHO website). The project analyses the health component of the PRSP from a pro-poor perspective; it looks at how far the overall PRSP document recognizes investments in health as important to poverty reduction. The overall aim is to examine whether the PRSPs are leading to the creation of more pro-poor health policies in low-income countries. A comprehensive desk review of PRSPs in ten countries from all parts of the world to see whether health had been given the MDG equivalent prominence revealed gaps in four major areas. First, the ministries of health, critical stakeholders in developing the health component, were largely marginalized during the PRSP formulation process. Second, the contents of the PRSPs were dominated by macroeconomics jargon, neglecting key social issues. Third, there was no analytical framework linking deficits in social indicators to causative factors. Lastly, there were no indications of how the gap (between

24

the resources expected from the HIPCPRSP mechanism and what was needed to meet the MDGS) will be closed. The review uses a standardized analytical framework that addresses seven main areas in order to analyse the povertyhealth links in the document:

component content of PRSPs in the Region was tabled and approved. It provides countries with the means for: (i) diagnosing health related development issues; (ii) analysing the linkages between poverty and health; (iii) elaborating pro-poor health policy interventions in the overall context of the PRSP, including the monitoring of outcomes; and (iv) costing the financial requirements of the health component, including a test for feasibility and sustainability of the level of resources. The rest of this article highlights the key aspects of this framework for enhancing the health component of PRSPs.2

Poverty-health context • Defining poverty • Examining the pattern of poverty • Examining the links between health and poverty Health-specific analysis • Health services • Communicable and noncommunicable diseases (including HIV/ AIDS) • Maternal and child health. • Health-related sectors (e.g., water, sanitation, nutrition).

Analytical framework The analytical framework involves a four-step process: (i) diagnosis of the current health situation, (ii) analysis of poverty and health linkages with a view to identifying key areas of policy intervention, (iii) quantitatively costing the health component of the national PRSP, and (iv) testing for short term feasibility of the proposed component, and for sustainability in the long term.

The framework systematically examines the poverty context outlined in the PRSPs from a health perspective, and the health strategy from a poverty perspective. In so doing, it assesses how prominently health features in the poverty analysis presented in the PRSP, and conversely, how far the health strategy responds to the poverty analysis. Second, it seeks to determine how far the health components of the PRSPs aim to improve the health outcomes among the poorest population groups and in the poorest regions. This is important because, although many of the health strategies outlined in the PRSPs are implicitly pro-poor, it is possible to achieve the MDG targets without reaching the very poorest. Third, the framework is informed by a review of actual country PRSPs which have already proved to be useful resources. Fourth, it allows an assessment of whether the health components of PRSPs are changing or evolving over time. Finally, the framework looks systematically at the link between the health targets and strategies set by PRSPs, and the MDG targets and indicators, allowing an assessment of how far the health MDGs are reflected in PRSPs. During the fifty-second session of the WHO Regional Committee for Africa, a proposal for enhancing the health

Current health situation The diagnosis of the current health situation reveals the linkages between poverty and health; it should be carried out at three levels. First is a diagnosis of the overall economic performance, which determines overall indicators such as infant and maternal mortality rates and access to clean water and sanitation. This process documents health expenditures, services and outcomes and relates the indicators of expenditures and services to health outcomes, thereby helping to evaluate the effectiveness or impact of public health expenditures on health.

2

Details of the suggested framework will appear in a guide for authors of the health chapter of PRSPs/ PRSs being prepared for the WHO-African Region. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Figure 1: Health sector matrix Trend analysis of past performance and resource allocation

Current situation of the main indicators1

Documentation of physical-financial relationships

Projecting desirable quantitative objectives

What is the current situation in terms of strategies, policies and interventions?

Trends over the past 10-15+ years of key health performance indicators

Illustrated health indicators for the past 10-15+ years2

Trends analysis of financial and physical aspects to infer/highlight linkages

Desirable objectives consistent with the expected resources

What are the objectives and what is the main orientation of health policy actions?3

Analysis of gaps between expected and achieved outcomes; clear explanations4

Analyses of recent changes of indicators with respect to resource availability and their geographic allocations

Extent to which different elasticities can be inferred or worked out on the basis of the trends to back a more efficient resource allocation and pro-poor budgeting

Analysis of consistency between planned objectives and other indicators5

1

Life expectancy at birth Infant mortality rate, maternal mortality rate Primary health curative care 4 Policy choices, global economic environment, resource scarcity 5 Absorptive capacity, changes in budget patterns 2 3

Policy intervention Such analyses permit the design of accurate policies based on situation analyses. The purpose is to identify key areas of policy intervention. Several of interventions should be considered: alleviating the burden of disease, increasing the supply of services in the social sector, strengthening communities, involving beneficiaries in health action and protecting household incomes. Poverty profiling shows the extent and depth of poverty: how many are poor, what are their characteristics, how poor they are, and where they are to be found. A diagnosis of the health sector produces an epidemiological profile with statistics on the burden of diseases of the poor (malaria, TB, childhood illnesses and HIV/AIDS). This culminates in a matrix of analysis and framework of policy interventions for the health sector (Figure 1). AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Quantitative costing of the PRSP health component It is essential to determine the cost of the health component of the national PRSP in absolute terms, relative to government budget and in percentage terms relative to gross domestic product (GDP) which can be used to measure sustainability of the planned national effort to deliver adequate health care to all, especially the poor. It also helps determine feasibility in the short term and sustainability in the long term. It can be used by the Ministry of Health to defend its budget within the government budgetary process. The costing approach uses two types of variables related to population and health expenditure.

Population-related variables P Total population in the country I Incidence of poverty–proportion of poor in the population

NP Absolute number of poor people in the population; calculated as NP=P*I. This forms the basis for calculating the cost of scaling up investments in health. It gives the number to which the per capita expenditures gap will be applied, hence the required resources (R).

Health expenditure variables HPC HRP GPC TC

Current per capita health expenditure Required per capita health expenditure Gap in health expenditures per capita; calculated as GPC = HRP - HPC Total cost of resources required for up scaling the health component of the PRSP; calculated as TC = GPC* NP.

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Testing for feasibility and sustainability

put so much of the available resources into health’?

A feasibility test considers all available types of expenditures, sources and allocations. It seeks to establish whether they will be available over the period under consideration and checks for consistency with the country’s macroeconomic framework. Feasibility is evaluated in terms of the available national resources (percentage of GDP), proportion of public health expenditures visà-vis total government budget (e.g. per capita health care expenditure as percentage of the government annual budget) and the proportion of public health expenditures available to expected HIPC resources. It seeks to answer the question “Can the country afford to

A sustainability test looks at the implications of the proposed health component over the long term, based on present circumstances, and seeks to answer the question, “Given the percentage of GDP devoted to health in the past, is the model realistic or achievable?” An affirmative answer suggests that implementation of the proposed component is feasible. An answer to the contrary would mean that the country is being asked to put in a disproportionately higher proportion of its available resources into health. This might imply diverting resources from other sectors in order to implement the health plan. In such

26

cases, the final action may rest with the political leadership.

Conclusion The health sector, from the MDGs perspective, has a central role to play in reducing poverty. Countries designing poverty reduction strategies need a framework to incorporate health concerns into their policies and plans. This article has outlined a simple approach to doing just that.

*Dr Mawaya is the Regional Advisor for Poverty and Ill-health at the Regional Office.

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

CHOICE: An aid to policy Health systems have multiple goals, but the fundamental reason they exist is to improve health. Yet health systems with very similar levels of health expenditure per capita show wide variations in population health outcomes. This can partly be explained by variation in nonhealth system factors, such as the level of education of the population; and partly by the fact that some systems devote resources to expensive interventions with small effects on population health, while at the same time low cost interventions with potentially greater benefits are not fully implemented. Cost-effectiveness analysis (CEA) is one tool decision-makers can use to assess and potentially improve the performance of their health systems. It indicates which interventions provide the highest “value for money” and helps them choose the interventions and programmes which maximize health for the available resources. CEA requires information on: the extent to which current and potential interventions improve population health, i.e. effectiveness1 and the resources required to implement the interventions, i.e. costs. The impact of interventions on population health is vital. But it is also important to determine the role of different interventions in contributing to other socially desirable goals, such as reducing health inequalities, and being responsive to the legitimate expectations of the population.

The role of CHOICE WHO seeks to provide the evidence decision-makers need to set priorities and improve the performance of their health systems. WHO’s Department for Health Systems Financing (HSF) in the Cluster AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

for Evidence and Information for Policy (EIP), has been assembling regional databases on the costs, impact on population health and cost-effectiveness of key health interventions. This work, known as CHOICE, started in 1998 with the development of standard tools and methods. The acronym CHOICE is derived from CHOosing Interventions that are Cost-Effective.

*Dr David Evans

CHOICE has been developing tools and methods for generalized CEA since 1998. Its objectives are to: • develop a standardized method for cost-effectiveness analysis that can be applied to all interventions in different settings; • develop and disseminate tools required to assess intervention costs and impacts at the population level; • determine the costs and effectiveness of a wide range of health interventions, undertaken by themselves or in combination; • summarize the results in regional databases on the World Wide Web; • assist policy-makers and other stakeholders to interpret and use the evidence.

**Dr Tessa Tan-Torres Edejer

interventions can increase population health with no change in costs. The second question is: “How best to use additional resources if they become available?” This type of analysis is critical for ensuring that as societies become wealthier, additional resources are well used. It is pointless asking this type of question if the current mix of interventions is inefficient. Both questions need to be asked together.

Why is it necessary to compare a wide variety of health interventions?

CHOICE permits both questions to be asked and both types of analysis to be undertaken simultaneously.

Policy-makers are concerned with two questions requiring evidence on costs and effects. The first is: “Do the resources currently devoted to health achieve as much as they could?” To answer this question, the costs and effects of all interventions currently employed must be compared with the costs and effects of alternatives. Reallocating resources from inefficient to efficient

1

Jamison DT et al, Disease control priorities in developing countries, Oxford University Press. (1993)

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Why do we need regional databases on intervention costeffectiveness? The pioneering effort of the World Bank’s Health Sector Priorities Review2 (HSPR) encouraged policy-makers to incorporate evidence on the costs and effects of interventions into their decision-making. The HSPR focused on a limited number of interventions, the individual studies used different methodologies, and estimates of cost-effectiveness were produced only on a global basis. This made it difficult for country policy makers to decide if the results across interventions were comparable, and if they were relevant to their settings. Epidemiology, baseline levels of infrastructure, the history of disease control and health promotion, and cost structures vary across countries. So the costs and effectiveness of any health intervention will vary from one setting to the next. Consequently, a single “global average” estimate for an intervention’s cost-effectiveness would not be of great value to decision-makers. However, the ideal of specific estimates for each intervention in every setting is not achievable in the short run. As a compromise, CHOICE has produced databases reporting the costs and effectiveness of interventions for 14 regions that have been grouped together on the basis of their similar epidemiology, infrastructure and economic situations. CHOICE has assembled regional databases on costs and population effectiveness and cost-effectiveness ratios of approximately 500 health interventions using a standardized methodology. CHOICE includes preventive, promotive, curative and rehabilitative interventions, both singly and in combination.

Can analysts adapt the estimates to their own settings? Regional databases represent a compromise between a single global database, that is not applicable locally, and

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the ideal of a separate database for each country, which is not feasible in the short run. However, CHOICE provides information allowing analysts to modify the results of the regional databases to their country.

past choices if necessary and feasible. They now have a rational basis for deciding to reallocate resources between interventions to achieve social objectives. CHOICE allows interventions to be evaluated singly or in combination with other interventions. It takes into account synergies between interventions on the costs and effectiveness or health systems side.

The databases include the raw cost and effect data, as well as the method and calculations that were used to obtain the summary cost-effectiveness ratios. The costing template accompanying all interventions uses an ingredients approach: quantities of resources used and prices are recorded separately. Effectiveness data is presented in a similarly transparent format. Analysts from different countries will be able to modify any of the base assumptions to make them consistent with their own settings.

How will the results help policy-makers? The CHOICE databases should not be used in a prescriptive way. They will reveal a set of interventions that are cost-effective in each region, a set that are not, and another set of interventions in between. Policy makers would then assess the appropriate mix for their settings, taking into account other goals of the health system as well as the improvement of population health. WHO will work closely with policy makers on ways of using the evidence CHOICE produces to achieve social goals.

CHOICE has developed computerbased tools that will be available for use by analysts. • PopMod is a population model used for measuring intervention effectiveness in terms of comparable units across different types of interventions and diseases. • The MCLeague program presents the cost-effectiveness results in a stochastic league table, i.e. explicitly taking into account uncertainty surrounding cost and effectiveness estimates of many interventions at the same time. • COST-IT is used to analyse and report cost data.

When will the CHOICE results be available? WHO-CHOICE has analysed cost, effectiveness and cost-effectiveness ratios of 500 interventions sorted out by the risk factors they address. The following are broad categories of interventions WHOCHOICE has evaluated: • • •

What other benefits does CHOICE offer? Generalized cost-effectiveness analysis forms the basis of the CHOICE approach.3 Uniquely, this method allows existing and new interventions to be analysed at the same time. Previous cost-effectiveness analyses have been restricted to assessing the efficiency of adding a single new intervention to the existing set, or replacing one existing intervention with an alternative. Using CHOICE, the analyst is no longer constrained by what is already being done, and policymakers can revisit and revise

• • •

Unsafe water, sanitation and hygiene; indoor air pollution Addictive substances Childhood undernutrition, pneumonia and diarrhoea; vaccine preventable diseases Other nutrition-related risk factors and physical inactivity Sexual and reproductive health, including HIV/AIDS Unsafe injections

2

Ibid. Murray CJL etal, Development of WHO guidelines on generalized cost-effectiveness analysis, Health Economics 9(3): 235-51, 2000. 3

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

• • • • • •

Iron deficiency Maternal and neonatal diseases Tuberculosis Malaria Mental disorders Blindness

Analytical work is going on to add a further set of 200 interventions for cardiovascular diseases and cancer. There will be comprehensive coverage of interventions ranging from prevention to rehabilitation, from individual to packaged interventions, from those addressing infectious to non-communicable diseases, including injuries and risk factors. The databases on the cost, effectiveness and cost-effectiveness ratios, together with the methodology are available on the internet (www.who.int/evidence/ cea) for public consumption. The databases are also expected to guide recommendations coming from within WHO

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

CHOICE has developed computerbased tools that are available for use by analysts. • PopMod is a population model used for measuring intervention effectiveness in terms of comparable units across different types of interventions and diseases. • The MCLeague program presents the cost-effectiveness results in a stochastic league table, i.e. explicitly taking into account uncertainty surrounding cost and effectiveness estimates of many interventions at the same time. • COST-IT is used to analyse and report cost data.

and will be offered as a resource to policy-makers who request technical assistance in priority-setting.

It is our hope that this evidence will guide policy-makers in the African Region to rationalize the choice of public health interventions with a view to ensuring that all possibilities of improving at least one person’s health status at no extra cost are exhausted.

*Dr Tan-Torres Edejer is the Coordinator, Costs, Effectiveness, Expenditure and Priority Setting (CEP) at WHO/HQ **Dr Evans is the Director of Health System Financing (HSF) at WHO/HQ

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The status of National Health Accounts in the African Region – By Takondwa Mwase

Introduction A major challenge facing countries in the WHO African Region is ensuring access to essential and high quality health services. This challenge has been brought about by a number of factors, including an increasing disease burden, limited economic resources and growing population. In order to respond to this situation, most countries in the Region are currently at various levels and stages of implementing health sector reforms and, in particular, financial reforms so as to raise additional revenue, and better utilize existing revenue, thus improving the performance of health systems. Available evidence shows that there has been very little progress made in implementing health sector financing reforms such as user fees, social health insurance and community financing schemes, among others as per capita expenditure on health continues to remain low in the

Region. One of the reasons for this poor performance is the weak stewardship role of governments which, has resulted in lack of vital financial information to guide sound health financing, policy formulation, monitoring and evaluation. Until recently, no country in the Region had any data on total health spending from all sources, contribution by each source or resource use. Without this information, there is little basis for making informed choices among health care objectives, evaluating alternative ways of financing and allocating resources or developing efficient and effective ways of providing services so as to improve the performance of health systems.

National health accounts National health accounts (NHA) provide a framework for gathering total actual expenditure on health. The NHA

tracks the flow of funds through the health system from sources of finance, e.g. ministry of finance through financing agents; ministry of health to hospitals or pharmacies. It also depicts spending by function and geographic area.. The NHA mainly responds to the following key questions: • Who pays and how much is paid for health care? • Who provides goods and services, and what resources do they use? • How are health care funds distributed across the different services, interventions and activities that the health system produces? • Who benefits from health-care expenditure? By providing answers to these questions, NHA provides information on the adequacy or otherwise of financial resources in the health system; the

Table 1: Flow of funds from sources to financing agents (US$ millions), 2000 Financing agents

Ministry of Finance

Ministry of Health

50

Local Government

5

Other govt. agencies

30

NGOs

30

Local Govt*

Sources Donors Firms 30

35

Firms

45

%

17.2

35

7.5

30

6.5

100

21.5

50

10.6

45

9.7

125

125

27.0 100

70

Health insurance

Total 80

30

Households out-of-pocket

30

Households

15

Total

115

30

100

80

140

465

%

24.7

6.5

21.5

17.2

30.1

100

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

nature of financial protection and the fairness of distribution of the financial burden; actual allocation of resources to priority interventions; effectiveness of public subsidies for health; emerging expenditure patterns; benchmarks for health spending; monitoring and evaluation of policy instruments. Table 1 is a matrix showing the flow of funds from the source of expenditure (columns) to financing agents (rows), answering the first question raised above: Who pays and how much do they pay for health? Subsequent tables could be constructed showing financing agents (columns) and providers (rows) and so on.

National health accounts in the African Region NHA was first introduced in early 1999 in eastern and southern Africa. However, prior to this, efforts had been made by WHO and the World Bank to collect health expenditure data in the Region using Health Expenditure Review and Public Health Expenditure Review frameworks respectively. By the end of 2001, 10 countries had undertaken NHA. In January 2003, the first west African NHA policy-makers sensitization meeting was held in Dakar, Senegal, with participants from 27 countries. This was followed by an NHA technical training course for 12 countries. Currently, there are 12 countries in the Region officially known to have completed one round of NHA. These are Algeria, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Rwanda, South Africa, Uganda, United Republic of Tanzania, Zambia and Zimbabwe. Some of these countries, including Ethiopia, Kenya, Malawi, Uganda and Zimbabwe, have embarked on a second round of NHA. The following countries are undertaking their first round of NHA: Gambia, Mauritius, Nigeria, Togo and Swaziland. Preparation for undertaking NHA is currently underway in Benin, Botswana, Burkina Faso, Cape Verde, Chad, Comoros, Ghana, Guinea, Madagascar, Mali, Mozambique, Niger, Senegal, Tanzania and Zambia. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

National health accounts results NHAs have been used in policy dialogue, and debate, design and implementation as well as in monitoring and evaluation in the African Region.

Policy dialogue NHAs have been used to inform debates, as a catalyst for change by attaching data that convey the magnitude of the problem, and as an advocacy instrument to stimulate action. In Kenya, before the NHA study was undertaken, policy-makers believed that government was the major financier of health services. After an NHA study, it was found that households, through direct out-of-pocket payments, were the major financiers of health services contributing 53% of the total expenditure. The government contributed only 19% of the total expenditure on health. This finding brought to the fore concern on the decline in relative importance of publicly funded services and reliance on out-of pocket payment for mainly outpatient services. This questioned government commitment to providing access to primary and preventive health care services. In addition, since user fees tend to dissuade the poor from utilizing health services, it is likely that the majority of the population was being denied access to health services. As a response, the Kenya Government is now in the process of designing a national social health insurance so as to reduce the huge direct out-of-pocket spending on health and thus encourages utilization of health services.

Policy design and implementation NHA results are also used for the formulation of specific strategies. In Rwanda, NHA results prompted donors to increase funding for HIV/AIDS. About 11.2% of the adult population in Rwanda is affected by HIV/AIDS. Owing to the magnitude of the disease, the government felt that a clear understanding of the sources of finance and the use of the resources for HIV/AIDS could go

a long way in designing appropriate strategies to tackle the pandemic. To effect this, the Rwanda Government decided to extend their NHA in 1999 which used data from 1998 to include a sub-analysis for HIV/AIDS. The NHA study revealed that about 51% of total health spending in Rwanda was financed by donors, and the government financed only 9% of the total health spending. The HIV/AIDS subanalysis revealed that only 10% of total health spending was used for prevention and treatment of HIV/AIDS. The most striking finding was that while donors were the major financiers of health care services in Rwanda, only 1% of the fund accounted for national expenditure on this deadly pandemic. It was also noted that in 1998, households bore the greatest burden of financing HIVAIDS interventions through direct out-of-pocket spending, at about 93%, while donors and government financed 6% and 1%, respectively. These findings exposed the inconsistency between policy statements on the priority attached to HIV/AIDS and the actual allocation of resources to deal with the pandemic. Following these findings, donors increased funding for HIV/AIDS interventions from US$ 0.5 million in 1998 to US$ 1.6 million by 2000. In addition, the government embarked on piloting prepaid community schemes so as to improve access to health care services for the population affected by HIV/AIDS.

Monitoring and evaluation In countries with regular NHAs intertemporal comparisons help to evaluate if strategies have had their expected impact. In South Africa, the NHA report published in 1995 found that health expenditure was higher than that of other countries at similar levels of development and yet the health status of the population was poor. It was also found that there were serious inequities in health and health care between regions, levels of care and population groups, and inefficiency in resource allocation and utilization. Following these findings, a major restructuring of

31

the health system commenced in South Africa. The NHA study conducted in 2000 using data for 1997 to 1999 was undertaken so as to monitor and evaluate whether resources had shifted to PHC and between levels of care; whether the health system was sustainable; whether equity had improved; and whether efficiency had improved. It was found that there were mixed results with regard to equity and efficiency. While there were some improvements in efficiency with regard to increase in resources to PHC, there was also an increase in resources going to the tertiary care level. This was due to changes in the funding mechanism which was no longer based on health needs but “conditional grants” for tertiary hospitals. Discussions are currently underway on developing appropriate funding mechanisms for tertiary care facilities and for funding provinces.

32

Challenges and perspectives The major challenges facing NHA development in the Region include limited awareness on the importance of NHA in health policy and planning, inadequate technical capacity and limited financial resources to collect quality data. Thus, in order to overcome these challenges, the WHO Regional Office for Africa in collaboration with partners has agreed to increase awareness of the relevance of NHA to policy-makers and civil society; strengthen technical capacity in the Region; provide technical and financial support to countries to undertake NHA studies; and institutionalize NHA in the Region.

Conclusion National health accounts are relevant tools for assisting in carrying out the health system function of stewardship

so as to accelerate heath sector reform implementation, thereby contributing to improvement of health systems performance. However, countries must ensure that policy-makers are made aware of the importance of this tool and that complete, accurate and consistent data are gathered and analysed for decisionmaking. It also requires transparency in agencies involved in health financing and reporting of health expenditures.

* Mr Mwase was, until recently, the Regional Adviser for National Health Accounts at the Regional Office. He is currently a team member of Abt/PHRplus in Malawi.

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Health financing reforms: the Nigerian experience Introduction Since Nigeria became independent in 1960, conscientious efforts at development have led to the formulation of various national development plans (the second for 1970–1974, third 1975– 1980, fourth 1981–1985 and fifth for 1987–1991). The adoption of the structural adjustment programme in 1986 was followed by a three-year rolling plan (1990–1992). In 1998, the Vision 2010 document was developed, and in 2003, the National Economic Empowerment and Development Strategy 2003– 2007 was put in place. The common objective of the development plans was how to achieve a free and democratic society; a just and egalitarian society; a united, strong and self-reliant nation; a great and dynamic economy; and a land of bright and full opportunities for all citizens. The health of the population is seen as a cornerstone of economic growth and social development. In furtherance of that principle, a national health policy was formulated in 1988 and revised in 1996 based on a philosophy of social justice and equity. The policy foundation adopted primary health care as the health system. This article discusses health system financing in Nigeria with a view to examining how financing matches the general principles on which the health system is based.

Organization of the health system The formal health system in Nigeria is organized along the three-tier system of government in the country: federal, state and local government. The federal level has responsibility for policy forAFRICAN HEALTH MONITOR JANUARY – JUNE 2005

mulation, implementation and evaluation as well as provision of tertiary and specialized care. The state level has responsibility for technical backstopping for the lower level of care in terms of implementation, and the provision of secondary level of care through general hospitals. Primary health care is the responsibility of local government authorities. All levels of government provide legislation and funding for the health system in the country. In terms of funding the health system, the National Health Policy articulates funding from budgetary sources, encouraging all levels of government to make adequate budgetary provision for the sector and, in particular, review their financial allocation to health in relation to the requirements of other sectors of the economy. Also recognized are additional avenues of revenue such as health insurance schemes and direct financing by employers of labour. Individuals are encouraged to establish and finance private health care while communities are encouraged to finance health care directly or find local community solutions to health problems through contribution of labour and materials. The public heath sector is financed with allocation from the Federation Account’s general revenue allocated to the various levels of government based on an agreed revenue allocation formula. The general mechanism for mobilization of revenue includes royalties and fees from the oil sector (the largest source of revenue for government); general tax revenue, including a value added tax; social health insurance; cost recovery, including user fees in some public health facilities; and external aid in terms of loans, donations and grants. The percentage of allocation to health has always been about 2-3% of

*Dr Amos Petu

the national budget, although this has increased marginally in recent times. Funding for the sector comes largely from government, more specifically the Federal Government. According to the World Bank, the public spending per capita for health in Nigeria is less than US$ 5 and can be as low as US$ 2 in some parts of the country. The Federal Government health recurrent budget showed an upward trend from 1996 to 1998, a decline in 1999, and a rise in 2000. The bulk of health recurrent expenditure went to personnel and construction of high technology hospitals that were at various stages of completion. Beyond budgetary allocations, another concern in funding the health sector in Nigeria is the gap between budgeted figures and the actual funds released from the Treasury for health activities. In some specific cases, statistics show that the actual amount released from the budget as low as 30–40% in a year. This has further heightened the need to support the development and refinement of a national health account so as to track the sources and flow of funds to and within the health sector. The mechanism for paying for services in the private health sector is through a fee for service. In very rare cases, some organizations and government departments engage in retainership, a practice whereby employees can benefit from health services up to a prescribed

33

monthly limit through a contracted private provider. The provider is reimbursed at agreed intervals. The major drawback of this scheme is that payment is made retrospectively. This implies that the provider must have the cash flow required for regular service delivery.

User fees in public facilities A user fee was introduced in the health sector in 1986. User fees, which are charged at all levels of health care (national and sub-national levels), have been extended to such components as surgical packs, drugs and dressings, and, in some instances, delivery packs. Experience has shown that these schemes seem to run better at higherlevel facilities like teaching hospitals but are very weak at general hospitals and health posts. This may be due to weak financial management capacity at these levels and the absence of clear retainer and use policy for fees collected.

Social Health Insurance The National Health Insurance Scheme (NHIS) was first broached in 1962 as a compulsory scheme for public service workers. Since 1999, the scheme has been modified to cover more people. This scheme of mandatory and payroll deductions, introduced by the NHIS Act 35 of 1999, allows each insured person to decide which health centre to register with. A monthly contribution is paid to the health centre. Health maintenance organizations are expected to play a major role in coordination of the health centres while the overall regulation of the scheme rests with the National Health Insurance Scheme Council.

34

The basic objectives of the scheme are to ensure that every Nigerian has access to adequate health-care services; protect families from financial hardship due to huge medical bills; limit the rise in the cost of health-care services; ensure efficiency in services; and ensure the availability of funds to the health sector for improved services, amongst others. Some stakeholders harbour fears regarding the implementation of the scheme. For example, organized labour, under the umbrella of the Nigerian Labour Congress, is weary of deductions from workers’ salaries as previous deductions for the National Provident Fund and the National Housing Fund did not benefit workers. While the NHIS is designed for the formal sector, the current effort at financing reform focuses on communitybased financing schemes with the hope that the various existing schemes can be subsequently pulled together for the benefit of the populace.

Current efforts in the general reform process The appointment of a new minister of health in July 2003 has rekindled the debate for reform in the health sector in general, and the financing of that sector in particular. In a recent public statement, the Health Minister called for the location of health sector reform within the overall goal of economic growth, development and stability, with reforms embracing crosssectoral issues, including public-private cooperation, management of public

expenditure, financial accountability and civil service reform. The Minister’s statement indicated specifically that the finance and budget management system would need significant improvement and enforcement. It is also important to note the effort at coordination with development partners through the Interagency Coordinating Committee. Although currently there is no common basket funding as such, the momentum generated at coordination meetings may lead eventually to that.

Conclusion The current health financing reform in Nigeria is laudable, given the fact that private expenditures, estimated at over 70% of total health expenditure, are mostly out-of-pocket payments in spite of the endemic nature of poverty in the country. Donors and other development partners are poorly coordinated; this has resulted in duplication of efforts, over-resourced programmes and some areas of the health system patently neglected. With the reform of the NHIS and better coordination of donors and partners within an institutionalized national health account framework, funding of health services will improve, leading to greater access to better quality of care for the Nigerian people.

*Dr Petu is the Health Economist at the WHO Country Office, Abuja, Nigeria

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Reform of health system financing in Senegal, 2004–2008 – by Dr Farba Lamine Sall

Introduction Generally, several countries are reforming their health system in a bid to enhance the efficiency and management of health services as well as the offer of these services, especially in favour of the destitute. As health systems are expanding and becoming more complex, policy-makers need to be equipped in order to ensure the efficient management of their health resources. In Senegal, as in most developing countries, two situations may be observed: (i) multiplicity of health actors, which accounts for redundancy in the funding of certain activities and lack of transparency in the use of resources; (ii) inefficient use of resources, which explains the differences between the increasingly important resources injected into the sector and the low benefit that the poor populations in particular are receiving. Deriving more benefit from the funding for the populations is a challenge to be met at a time when there are increasing numbers of public funding opportunities.1 In Senegal, resources for the health sector are mobilized from four main sources. For the first phase of the national health development programme (PNDS) (1998–2002), these sources were: the state (49%), local authorities (3%), populations (15%), development partners (33%).2

Background The analysis of government funding of health shows that considerable financial efforts were made, in the past years, in favour of health services in general and basic health in particular. These efforts AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

made it possible to increase basic infrastructures and improve health coverage in peri-urban and rural areas. According to the results of the final evaluation of the first phase of the PNDS (1998-2002), coverage in pre-natal consultation increased from 44% to 69% between 1996 and 2002, while the completion rate rose from 44% to 54.2%. Assisted deliveries also increased from 31% to 55% and the number of fully immunized children from 33% to 67% during the same period. Total fertility rate for women aged between 15 and 49 years declined from 5.7% to 5.2% between 1997 and 1999.4 These data indicate that appreciable efforts were registered. However, inadequacies in the efficient mobilization and use of resources are still weaknesses increasingly decried, which are distorting the results that could have been obtained from the flow of funding registered in the sector. To eliminate the above weaknesses observed during the evaluation of the first phase of the PNDS (1998-2003), the State authorities, especially those in the Finance Ministry, have decided to adopt reforms aimed at enhancing the capacity to mobilize and absorb resources, while ensuring clarity and transparency in the use of these resources. There are, however, some weaknesses in the efficient mobilization and use of resources within the set timeframe, that are increasingly observed, and which are distorting the results that could have been obtained from the flow of funds registered in the sector. The following reforms will be undertaken and enforced with effect from 2004, at the start of phase II of the PNDS:

budget support, decentralization of expenditure authorization, medium term expenditure framework of the national health account and macro-economy and health approach.

Budget Support Adopted as a strategy for government funding in the health sector is the framework for the implementation of the Poverty Reduction Support Credit. Budget support is a prerequisite for mobilizing resources for attaining the results to be measured according to pertinent indicators of the sector. With the ninth EDF, the European Union is striving to develop, in collaboration with the Government of Senegal (ministries of finance, health and education), a macro-economic support programme amounting to 53 million euros.3 The African Development Bank (ADB) plans to place the health sector on the agenda of its future interventions under this result-based funding scheme. The budget support will consist in transfer-

References 1 Support and Monitoring Unit of the PNDS: Preparatory documents of Phase II of the PNDS, February 2004. 2 DIENG K. Eléments constitutifs du Rapport de la Phase I du PNDS (1998-2002) février 2004. 3 NDIAYE I.: Note de présentation sur l’appui budgétaire octobre 2003. 4 NDOUR M. C: Note de présentation du Crédit de soutien à la réduction de la Pauvreté CSRP/Santé, janvier 2004.

35

ring to the national budget resources from development partners that subscribe to the scheme. This will consequently increase the budget allocation for services benefiting from these support initiatives and which correspond to the volume of activities funded by these partners.

The decentralization of expenditure authorization, limited for the 2004 fiscal year to the central departments of the ministries concerned, required that measures be taken to strengthen the organization and technical capacities of the Ministry of Health to enable it to carry out the resulting new tasks.

As they are included in the national budget, these budgets will be financially executed in accordance with government accounting rules and procedures.

More specifically, this will involve strengthening the capacities of the department charged with this responsibility. The measure should be taken concomitantly with the strengthening of management capacities of the central services.

To facilitate the mobilization of resources, the revolving funds will be reopened, taking into account the conclusions of the study on the possibility of injecting more funds into the facility before the end-of-year audit, since the two operations are not related. At the organizational level, this new funding strategy calls for strengthening the accounting and procurement procedures of the health district. To that end, it is proposed to establish a management office comprising two sections, one section in charge of accounting and the other in charge of contracts.

Decentralization of Expenditure Authorization The evaluations of the public finance management system underscored the need for gradual introduction of reforms in the channel for mobilizing and utilizing resources allocated to certain pilot sectors, including health. It was therefore decided to entrust the expenditure authorization functions to the ministries.

The Ministry of Health is expected to take the following measures: (i) creating a division within the Department in charge of expenditure authorization; (ii) adopting a decree on delegation of the signature of the Ministry of Health to the official with power to authorize expenditure; (iii) allocating offices to the financial operations controller attached to the Ministry of Health.

essary monitoring of the attainment of the aforementioned objectives. Other actions to be taken include the amendment of the legal framework, training, technical and logistical support, which fall within the scope of the Ministry of Economy and Finance and have an impact on the implementation of the above-mentioned activities.

Medium-term Expenditure Framework The programme approach is maintained for the second phase of the PNDS. Consequently, it has been decided to systematize the development of a medium-term expenditure framework (MTEF) as a tool for programming and at rationalizing the interventions in order to ensure efficient use of the resources allocated by the different actors.

The other levels of the health system (regions and districts), concerned by the reform with effect from 2005, will be prepared now to assume these new responsibilities.

Based on the data collected from the four sources, (state, local authorities, populations and development partners) as of 11 March, the medium-term expenditure framework of the health sector covering the period 2004-2008 was developed (see Table 1).

Entrusting more responsibility to the ministry at the different levels (central, regional and district) should be accompanied by the establishment of budget monitoring mechanisms in order to ensure transparency, security, promptness and efficiency in the execution of the operations. To that end, the Ministry of Health should be strengthened in terms of human resources, training and equipment in order to facilitate the nec-

Of the 22 that partners intervened during the first phase of the PNDS, only 11 have indicated their intention to fund activities under the new programme. It should be recalled that the contribution of development partners to the funding of the first phase programme, which has just ended, represented 30% of the total cost. There is every reason to expect the same level of commitment in the coming months.

Table 1: Medium-term Expenditure Framework (million CFA francs) 2004

2005

2006

2007

2008

TOTAL

%

State

56 183

60 519

65 314

70 618

76 486

329 120

62%

Local Authorities

4 316

4 316

4 316

4 316

4 316

21 580

4%

Populations

27 229

27 229

27 229

27 229

27 229

136 145

26%

Partners

21 284

9 661

6 783

4 721

1 705

44 154

8%

TOTAL

109 012

101 725

103 642

106 884

109 736

530 999

100%

36

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

The planning and budgeting per objectives will be based on the MTEF and the intervention orientations defined in PNDS II. The objectives will be taken into consideration during the allocation of resources. This MTEF programming tool should enable the Ministry of Health to efficiently monitor the expected funding opportunities in the sector, to better exploit them and especially to avoid losing funds for failing to consume them (lack of control of the funding procedures, lack of information). In fact, the Ministry of Health is quite often criticized for its weak capacity to mobilize both domestic and foreign resources.

National Health Accounts The need for transparency and control of the different flow of funds is today shared by both the authorities of the Ministry of Health and those of the Ministry of Economy and Finance. The multitude and diversity of producers, sources and funding agents are further complicating funding efforts, thereby making it difficult to attain the objective of ensuring the efficient use of resources to effectively meet health demand by taking care of populations in poor areas. To that end, the production of national health accounts constitutes one of the most important actions that should equip actors of the sector in their declared desire to ensure greater efficiency in the use of resources. This basic exercise will be carried out by the team set up at the end of the training workshop on national health accounts organized and conducted by the Regional Office in Dakar from 29 September to 3 October 2003. It aims at attaining the following specific objectives: • To identify the different sources of funding and their trend, using the concept and principles of national health accounts; • To analyse the trend of expenditure of funds devoted to health through AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

the implementation, monitoring and evaluation of national health accounts; • To analyse the distribution of health expenditures at the various levels of the health pyramid (primary, secondary, tertiary and administration); • To analyse health expenditures per type of expenditure (investment expenditures and operational expenditures) and per expenditure item (staff expenditures, recurrent expenditures and expenditure on drugs). The processing of data on the different flows of funds will enable the Ministry of Health to play its regulatory role in order to bring about a more equitable distribution of health within the country and among zones and their populations. With the support of the WHO, Senegal should produce these national health, accounts, at the latest, in the course of the 2006-2007 biennium.

Macroeconomy and Health Approach During phase II of the PNDS, Senegal, with the support of WHO HQ, will embark on the development of an investment support programme as part of the extension of “pro-poor” services, as recommended by the conclusions of the Macroeconomics and Health Committee. This phase will, in fact, enable the country to acquire capacities to advocate for major additional investments,5 which are expected to contribute not only to an improvement of the health status of the population but also to poverty reduction. The objective of the Macroeconomics and Health approach is to enhance the sustainability of the programme and reduce dependency on external support. During the second phase of the PNDS, the approach will focus on three main themes: (i) improvement of the health status of the poor; (ii) mobilization of additional resources for health; (iii) elimination of non-financial constraints

in order to strengthen the absorption capacity for provision of health services through a series of reforms, where necessary. In order to achieve these results, Senegal started receiving support from KIT Amsterdam in February 2004, at the request of WHO HQ. During that year (2004), Senegal expected the following forms of support from KIT: • Assessment of the specific situation of the country from macroeconomics and health point of view, taking into account current programmes such as PSRP, MDGs and NEPAD; • Analysis of the process including the institutional framework of a Senegalese Select Committee for the development and implementation of a macroeconomics and Health plan; • Assistance needed for the second phase; • Development of an action plan for the second phase, including a logical framework for macroeconomics and health activities; • Identification of the problems encountered (including actions for resolving them). The establishment of the macroeconomics and Health Committee and commitment of the highest government authorities to ensure its functioning will mobilize more actors in a funding environment made clearer and more transparent through the production of national health accounts and a medium-term expenditure framework.

5

TOONEN J.: Appui technique à Macroéconomie et santé au Sénégal - Etat des lieux, KIT/OMS, mars 2004.

37

On the whole, the various government reforms are aimed at mobilizing more resources for the sector, ensuring greater transparency and promptness in their increased use through improved absorption capacity in order to effectively meet the health needs of the population in general and the poor in particular.

Local authorities Since 1 January 1997, the local authorities (regions, districts, urban districts and rural communities) are fully exercising their management responsibility. The health sector is part of the areas of competence transferred to local authorities, which are now receiving funds to cover the operational expenses of health structures under their responsibility. The endowment funds were not received during the first semester of the budget year concerned. This imposed a serious strain on resources expected for community participation and, consequently, a dramatic strain on the prices set for users, particularly the poorest population groups. To remedy the situation, which is affecting the functioning of health structures and opportunities for meeting the health needs of the poor, the ministries involved in the process of determining and allocating endowment funds must take the necessary measures before the end of the first semester of the budget year. This would help avoid, or at least limit delays in mobilizing resources intended for the health sector from the local authorities, which have been made aware of their responsibilities in the framework of the decentralization process. The time saved in resource mobilization will be all the more beneficial to the sector since, from the year 2003, all the local authorities in the country started receiving funds from the health sector as from 2003, the year this measure was extended to the rural communities.

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Population The promotion of financial access to care is the most significant contribution made by the Ministry of Health under the National Poverty Alleviation Programme, as it facilitated access of poor populations to basic social services. Indeed, the government has clearly indicated its intention to reduce the cost of health for the population in general and the poor in particular. This option consists of mobilizing funds to offer, as from 2004, free care and treatment of certain priority health problems identified in the context of the PNDS (maternal mortality: PNC, deliveries and caesarean operations) for populations of the four poorest regions of Senegal. This coverage will be extended geographically and to other health problems in the coming years. This will reduce the pressure on the prices set for users and part of the funding borne by the populations, representing about 25%. At the same time, the government will continue to support mutual benefit initiatives and provide necessary access facilities by obtaining from its care structures, procedures enlightened through contracting with mutual insurance companies, and a control of costs of services it will continue to subsidize.

Partners The major innovation in the funding by development partners intervening in the health sector is the adoption, by some of them, of the budget support scheme. Initiated by the government as a means of funding and adopted by the World Bank, ADB and the European Union, budget support constitutes a major step in the process of harmonizing the procedures of partners participating in the funding of the sector. The positive results obtained with this new approach could encourage other partners, which

for the moment are submitting to concerted planning with the ministry at the different levels of the health system, to adopt it. An exhaustive and regularly updated identification of funding actors in the different areas and intervention structures is envisaged to meet this need for synergy, complementarity and harmonization in order to ensure greater efficiency in the use of resources earmarked for the same objectives. Finally, it should be pointed out that the support of partners for the medium-term expenditure framework and their concern was to see the Ministry of Health improve its organization in order to better benefit from the multiple support opportunities for the health sector and, consequently, for the populations whose health needs are yet to be met.

Conclusion The challenge facing the Ministry of Health for the next five years of the PNDS is to produce results commensurate with the resources programmed for the sector. Sector performance will be appreciated when the population has access to quality care, observes an improvement in their health status and experiences a reduction of health costs in general and for the most destitute in particular. The effective execution of these reforms will ensure efficient use of resources. The monitoring of the implementation of the reforms should occupy a central place in the agenda of the Ministry of Health in the coming years.

* Dr Sall is the Health Economist at the WHO Office in Dakar, Senegal

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Technical efficiency of health centres in Sierra Leone “Public health is the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort.” 1

Introduction Sierra Leone has a population of 4.6 million and a total fertility rate of 6.5. Its health indicators are poor. For example, the life expectancy at birth is 34.2 years, probability of dying (per 1000) before the age of 5 years is 313, and probability of dying (per 1000) between ages 15 and 59 years is 6192. These dismal health indicators are partly a reflection of poor national health system performance.3 Health centres are a critical part of the

national health system in Sierra Leone. As pointed out more than 85 years ago by Prof. CEA Winslow, an American public health expert, part of the mandate of the public health discipline ought to be promotion of efficiency, i.e. to maximize the benefit of health interventions (promotion, prevention and preventive treatment) to communities at large from the available scarce resources. Therefore, decision-makers need to ensure that health centres (and all other aspects of the public health system) are providing services efficiently.

*Ade Renner

A recent study applied the data envelopment analysis (DEA) method to investigate technical efficiency among a sample of 37 public health centres in Sierra Leone.

**Dr Joses Kirigia

Overview of a public health system Figure 1: Public health system conceptual framework

Public Health System Purpose & substance

Public Health Functions

Assuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care. Assessment of health of the community. Policy development in public interest.

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Inputs

Professor BJ Turnock4 developed a conceptual framework that ties together the mission and functions of public health to the inputs, processes, outputs and outcomes of the system (see Figure 1). According to Turnock, a public health expert, a public health practice, such as a health centre employs multiple inputs to produce multiple outputs (see Figure 2).

Public health practice

Outputs

Health Outcomes

1

Winslow CEA The untilled field of public health. Modern Medicine; 2: 183-191, 1920. 2 WHO, The World health report 2002: reducing risks, promoting healthy life, Geneva, World Health Organization: 2002. 3 WHO, The World Health Report 2000: improving performance of health systems, Geneva, World Health Organization, 2000 4 Turnock B.J. Public health: what it is and how it works. Aspen Publishers, Inc: Gaithersburg, 1997.

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Figure 2: Public health practice

1. Technical staff (vaccinator, community health nurse, emergency and humanitarian officer, maternal and child health aide)

Health Centre Services

2. Subordinate staff (TBA, porter, watchman)

Data envelopment analysis conceptual framework Confronted with the public health practice contained in Figure 2, the data envelopment analysis approach defines efficiency as the ratio of the weighted sum of outputs of a health centre to its weighted sum of inputs.5 This mathematical programming technique establishes a production possibilities frontier based on relatively efficient health centres and measures how far inefficient health centres are from this best public health practice frontier. The health centres that are technically efficient are assigned a score of 100% and the inefficient ones a score of less than 100%. The higher the score, the greater the efficiency and vice versa.

1. Antenatal + postnatal care 2. Babies delivered 3. Nutrition/growth monitoring visits 4. Family planning visits 5. Under 5s immunized + women immunized 6. Health education sessions

The DEA model was estimated with a total of eight variables: six outputs and two inputs. Table 1 presents descriptive statistics (means and standard deviations) for the 37 public health centres output and inputs in Sierra Leone. Technical efficiency scores for each of the 37 health centres are portrayed in Figure 3. Out of the 37 health centres, 15 (41%) were found to be relatively technically efficient since they had a score of 100%. The remaining 22 (59%) health centres were technically inefficient since they had scores of less than 100%. Seven (47%) of the latter health centres had a score below 50%. Overall average techni-

cal efficiency score was 78%, with a standard deviation of 23%. Average technical efficiency among the inefficient health centres was 63%, with a standard deviation of 18%.

Discussion The results obtained in Sierra Leone were very similar to those obtained from the efficiency analysis of Kenyan health centres which found 56% of health centres to be technically inefficient, with an average technical efficiency score of 65%.6 In KwazuluNatal Province of South Africa, 70% of primary health care clinics were found to be technically inefficient.7

5

Charnes A, Cooper WW and Rhodes E. Measuring the efficiency of decision-making units. European Journal of Operations Research, 2(6): 429–444, 1978. 6 Kirigia JM, Emrouznejad A, Sambo LG et al, Using data envelopment analysis to measure the technical efficiency of public health centres in Kenya , Journal of Medical Systems, 28(2): 155-166 2004. 7 Kirigia, JM, Sambo, LG and Scheel H, (2001). Technical efficiency of public clinics in Kwazulu-Natal province of South Africa, East African Medical Journal, 78(2): S1-S13, 2001.

Table 1: Public health centres outputs and inputs, Sierra Leone Variables Outputs Antenatal plus post natal care (ANC)

Mean

Standard deviation

25 099

678

749

4 863

131

99

29 633

801

1 045

2 958

80

55

33 399

903

846

7 458

202

118

Inputs Technical Staff

78

2

1

Subordinate staff

27

1

1

Deliveries Nutrition/growth monitoring visits (NUT) Family Planning visits (FP) Expanded Programme of Immunization (EPI) Health Education Sessions (HES)

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Total

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Figure 3: Technical efficiency of health centres

18% of health centres in Ghana were inefficient.8 About 83% of the Zambian health centres which featured in the study were technically inefficient.9 Thus, Ghana had the least percentage of inefficient health centres compared to Kenya, Sierra Leone, South Africa and Zambia. Figure 4 shows the total output increases or input increases needed to make inefficient public health centres efficient. In order to become efficient, the 22 inefficient health centres combined will need to increase their current output levels by 57% regarding antenatal and postnatal care visits; 50% deliveries; 85% growth monitoring visits; 45% family planning visits; 40% immunization visits and 36% health education visits. This potential for providing more preventive health services to those currently without access, at no extra cost, is of great public health importance in a poor country like Sierra Leone, where large numbers of pregnant women do not have access to antenatal care and trained attendants during childbirth; a large percentage of children are underweight, stunted and wasted; and a large proportion of children do not have access to the Expanded Programme of Immunization (EPI) that targets diphtheria, tetanus, whooping cough, polio, tuberculosis and measles (see Table 2). Whereas, the scope for savings on staff cost in Sierra Leone is almost non-existent, as revealed by this study, there is certainly scope for providing essential public health services to a significantly larger number of people than the health centres are currently providing. This can be achieved through conscious pursuit of health promotion strategies10 to create or induce demand for essential preventive public health services, that are currently grossly underutilized.

Figure 4: Total output increases needed to make inefficient public health centres efficient

Conclusions This study has demonstrated the usefulness of the DEA method in the measurement of technical efficiency among a sample of public health centres in Sierra Leone. It has also illustrated how such analysis can be used in pursuit of the public health objective of promoting efficiency. There is therefore need to replicate the type study among the remaining health facilities in Sierra Leone, and, indeed, in other countries in the Region, with a view to implementing the necessary actions to ensure optimal service delivery.

8

Osei D, George MO et al, D’Almeida S,. Technical efficiency of public hospitals and health centres in Ghana: a pilot study. (unpublished paper). Brazzaville: World Health Organization, Regional Office for Africa, (2002). 9 Masiye F, Kirigia JM et al, Emrouznejad A, Efficiency of health centres human resources in Zambia. “Mimeo”. Brazzaville: WHO/AFRO. 10 Nyamwaya D, Trends and factors in the development of health promotion in Africa, 1997-2003. In: Scriven and Garman, Promoting health: global perspectives, pp. 167-177 London: Palgrave MacMillan, 2005. AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

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While health leaders and managers ponder whether to take steps to improve efficiency in health care or not, it is important to always remember the words of Professor G. Mooney: “Without a wider use of economics in health care, inefficiencies will abound and decisions will be made less explicitly and hence less rationally than is desirable: we will go on spending large sums to save life in one way when similar lives in greater numbers could be saved in another way. The price of inefficiency, inexplicitness and irrationality in health care is paid in death and sickness.”11

As demonstrated in this article, quantitative tools such as DEA can help policy-makers and managers to answer the questions “How efficiently are individual health facilities performing?” “What specific inputs are being used inefficiently?” and ‘What are the magnitudes of output increases and/or input reductions needed to make inefficient health facilities efficient”. Judicious application of such methods could empower health leaders and managers to get more value (in terms of reductions in the burden of debility, morbidity and mortality) from the current investments in the health sector.

*Mr Ade Renner is Health Economics Advisor at the WHO Country Office, Freetown, Sierra Leone **Dr Joses M. Kirigia is the Regional Advisor for Health Economics, Regional Health Economics Programme at World Health Organization, Regional Office

11

Mooney G, Economics, medicine, and health care, New York, Harvester Wheatsheaf, 1986.

Table 2: Inaccessibility to basic health centre services in Sierra Leone Health Manifestations

%

Pregnant women without access to prenatal/antenatal care

32

Pregnant women without access to trained attendants during childbirth

58

Married women aged 15-49 years not using contraceptives

96

Newborns weighing less than 2.5kg at birth

22

Children (0-59 months) whose weight falls below -2 standard deviation of the median of the international (NCHS) reference population

27.2

Children (0-59 months) whose weight falls below -3 standard deviation of the median of the international (NCHS) reference population

8.7

Children (0-59 months) suffering moderate stunting

33.9

Children (0-59 months) suffering severe stunting

15.8

Children (0-59 months) suffering moderate wasting

9.8

Children (0-59 months) severe wasting

1.9

Infants not fully immunized with

BCG

61

DPT3

76

OPV3

74

Measles

57

TT2

80

Population without access to safe water

57

Population without access to sanitation facilities

57

Population without access to health care services

70

Sources: UNICEF http:/www.childinfo.org/and WHO Regional Office for Africa. Basic Indicators 2002: health situation in the WHO African Region. Brazzaville: WHO/AFRO.

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AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

National health accounts: the Namibian experience Background National Health Accounts (NHAs) are vital tools for diagnosing the financial functions of health systems and designing sound health financing policies. They should lead to an improvement in the performance of health systems and, ultimately, to an improvement in the health status of the population. Namibia, with a surface area of 824 116 square kilometers, is located in the southwestern part of the African continent. The country has a population of 1.8 million and a population density of 2.1 persons per square kilometre. With a per capita income of US$ 1,980, the country is classified as a middle-income country. However, the per capita income masks the reality of a high degree of income inequality. According to the world health report 2000, the Namibian health system consumed around 7.5% of Gross Domestic Product, but the health outcomes in terms of disability adjusted life expectancy were poor compared to other countries at similar levels of development and with similar levels of health expenditure per capita. This scenario has raised questions about the allocative and operational efficiency and equity of the health system. Policy-makers were concerned that in a country with a legacy of high levels of inequality in health and access to resources, establishing a NHA was of paramount importance to redress ills of the health system inherited from the pre-independence political dispensation. Furthermore, since 2000, the Ministry of Health and Social Services (MoHSS) had, on various occasions, been requested by WHO to provide and validate ratios and per capita levAFRICAN HEALTH MONITOR JANUARY – JUNE 2005

els of national health expenditure as part of its contributions to world health reports. On many occasions, the expenditure figures could not be validated, as no study was done to determine the national health expenditure in the country.

*Mr William Kapenambili

The objective of this article, therefore, is to share the Namibian experience in establishing a national health account.

Situation analysis and training As a first step, the MoHSS solicited technical support from WHO. In response to the request, WHO sent a mission to Namibia to undertake a situation analysis. WHO also supported the training of three MoHSS staff members on NHAs in Zambia.

**Mr Thomas Mbeeli

The report of the situation analysis helped to map out the flow of funds in the system and evaluate the resource implications of undertaking the study. It also led to the constitution of a multidisciplinary NHA team with members from both within and outside the MoHSS.

Workshops and data collection The Ministry of Health and Social Services conducted a sensitization workshop for potential stakeholders. The workshop was intended to solicit cooperation and clarify any misconceptions about the nature of the exercise. To underscore the importance of the exercise, the keynote address at the workshop was delivered by the Deputy Minister of Health and Social Services.

***Mr Ben Tjivambi

Generic questionnaires used by other countries to develop their NHA were

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collected by the NHA team and adapted to suit the Namibian situation. Seven types of questionnaires where thus developed, all geared towards collecting information from health insurance companies, donors, nongovernmental organizations, development partners, employers, the MoHSS and other government ministries. Prior to the data collection process, a second sensitization meeting was held with the aim of introducing the questionnaire to all potential respondents. This meeting was officiated by the Permanent Secretary and Under Secretary (Policy Development and Resource Management) of the MoHSS. The presence of high-level MoHSS officials was meant to underline the importance of the meeting. For the data collection exercise, 15 field workers were recruited from a pool of experienced survey interviewers; they were given a three-day training session before embarking on fieldwork. The training was very important as it helped the enumerators to understand the questionnaires as well as the terminology used in NHA. Questionnaires were distributed to the various organizations by enumerators

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and were collected a week after delivery. E-mail was also used for delivery of questionnaires to some organizations. The data collection and follow-up process lasted for two months. An Excel spreadsheet with features of the questionnaire was created to allow for data entry. After the data was cleared for consistency, and all followups with the various respondents were done, data were entered into the Excel template. A weeklong data analysis workshop was organized with the technical support of WHO. The involvement of WHO in all phases of the study also helped to boost the capacity of the NHA team.

The main enabling factor in the finalization of the NHA study was the support the team had received from senior management of the MoHSS as well as all levels of WHO: Country Office, Regional Office and Headquarters. The constraint in the preparation and finalization of the study was the lack of technical capacity and skills in the MoHSS with regard to health equity analysis as well as lack of hands-on experience in NHA. As NHA is an essential tool for evaluating on-going health reform strategies, Namibia plans to institutionalize this tool with a view to making it part of its routine Health Management Information System.

Conclusion The NHA as a tool for policy-makers has had a positive impact on operations in the Ministry of Health and Social Services. Some of the recommendations of the NHA team are already being implemented. These include equalization of per capita regional allocation over a period of time and research to formulate a needs-based resource allocation formula.

*Mr Kapenambili is the Chief Health Programme Officer in the Division of Policy and Planning **Mr Mbeeli is the Chief Health Economist in the Ministry of Health and Social Services ***Mr Tjivambi is the Senior Health Programme Administrator in the Division of Policy and Planning

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Annex 1: Summary of the NHA experience Activities: 1.

Development of NHA study proposal

2.

Soliciting financial support for the proposal

3.

Mission to Namibia to undertake a situation analysis

4.

Training of MoHSS staff members on NHA

5.

Situation analysis report produced

6.

Mapping of the flow of funds in the health system using the situation analysis

7.

Evaluate the resource implication for undertaking the study

8.

Institute a multi-disciplinary NHA team

9.

Sensitization workshop for potential stakeholders

10.

Adaptation of the generic questionnaire to suit Namibian situation

11.

Second NHA sensitization workshop held prior to data collection

12.

Recruitment of fieldworkers from pool of survey interviewers

13.

Three day training of fieldworkers

14.

Distribution of questionnaires to various respondents

15.

Follow up process on the questionnaire

16.

Data entry into excel spreadsheets

17.

Week-long data analysis workshop with technical support from WHO

18.

Presentation of preliminary findings to top management

19.

Draft report produced

20.

Draft report distributed within MoHSS

21.

Present draft report to Ministerial Management Committee Meeting for approval

22.

Report forwarded to all levels of WHO for further inputs

23.

Inputs from all stakeholders incorporated

24.

Printing of the report

25.

Launch of the report by the Permanent Secretary

26.

Distribution of copies to all stakeholders

27.

Second round of the NHA process in progress

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

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Implementing the macroeconomics and health strategy: the Ghanaian experience *Selassi Amah d’Almeida

Introduction

Multisectoral GMHS

The government of Ghana recognizes health not only as an outcome but also as a critical input for economic growth and development. It also recognizes the need to increase investment in health, as health does not only produce wealth but engenders economic development and poverty reduction, especially for the poor. This perception is in line with the recommendations of the Commission on Macroeconomics and Health (CMH) report which was presented by Prof. Jeffrey D. Sachs to Dr Gro Harlem Brundtland, the then Director-General of the World Health Organization in December 2001.

by Selassi Amah d’AlmeidaThe Minister of Economic Planning and Regional Cooperation, in collaboration with the ministries of health, finance, local government and rural development and other key health-related agencies such as the Community Water and Sanitation Agency coordinated the multisectoral aspects of the strategy. The group subsequently produced a report, “Investing in Health and Macroeconomic Development in Ghana”. The strategy was to harmonize selected national health-related priorities in the PRSP and the recommendations made by the CMH, while ensuring consistency with a sound macroeconomic policy framework.

Initial advocacy and build-up To rally support for the implementation of the CMH recommendations, the WHO Representative in Ghana started advocacy with influential and eminent Ghanaians. He first briefed the Minister of Economic Planning and Regional Cooperation on the CMH recommendations and its implications for poverty reduction in the light of Ghana’s Growth and Poverty Reduction Strategy Paper. A briefing was subsequently organized for the Chairman of the Council of State (an advisory body to the President and the Government), followed by a presentation to the members of the Council. The Minister of Economic Planning and Regional Cooperation and the Chairman of the Council of State showed interest in the prospects of Ghana adopting and implementing the CMH recommendations, and subsequently became the driving force behind Ghana’s Macroeconomics and Health Strategy.

46

Aims and objectives The overall goals of the strategy are to: • Disseminate and discuss widely in-country the findings and recommendations of the CMH report; • Provide strategic options for scaling-up investments in sectors that influence the health status of Ghanaians in order to have the desired impact on poverty reduction and economic growth in the shortest possible time; • Mobilize of political support and advocacy at the local and international levels to attract more resources to water, sanitation and health.

Structure In line with WHO guidelines, two national committees (advisory and technical) were formed to pursue the

aims of the strategy. The two committees constitute the equivalent of the National Commission on Macroeconomics and Health for Ghana.

Advisory Committee The Advisory Committee was to provide guidance for the formulation of the macroeconomics and health strategy and to advocate at the national and international levels. Members of the Committee include the ministers of health, economic planning and regional cooperation, finance; local government and rural development, and works and housing. The other members were the Majority Leader of the Parliament, Representatives of the Parliamentary Select Committee on Health, the Chairman of the Council of State, the Director-General of Ghana Health Service, the President of Ghana Insurers Association, the ViceChancellor of the University of Ghana, and the Country Representatives of WHO, UNDP, UNICEF, DFID and the World Bank. This committee held its first meeting on 31 July 2002.

Technical Committee The Technical Committee was made up of representatives of the ministries, departments and agencies represented on the Advisory Committee, the Community Water and Sanitation Agency, the Ghana Water Company the Environmental Health unit of the Accra Metropolitan Authority and WHO. This committee was charged with producing draft technical papers, with the main inputs being the PRSP, sectoral plans and programmes and the AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

recommendation of the CMH report. The Technical Committee was also to make recommendations for scaling up investment in health care, water and sanitation in order to achieve high coverage levels of targeted health interventions and per capita health expenditure recommended in the CMH Report. This committee was also to produce a document which would serve as an addendum to the PRSP as well as an advocacy tool and investment plan to attract more resources to health-related areas. The committee held its first meeting in July 2002, followed by weekly meetings until the end of October 2002 when the draft papers were ready.

Joint meetings The technical and advisory committees held joint periodic meetings to discuss and resolve policy and technical issues arising out of the draft technical papers. They also discussed their work programmes, reviewed progress of work done and suggested the way forward regarding the realization of strategy objectives. The joint meetings were also to foster interaction and rapport-building between the two committees to ensure that the views and recommendations of the Advisory Committee were reflected in the technical papers.

Preparation of technical papers The Technical Committee was tasked with generating evidence pertaining to health problems and their link to poverty in Ghana. In working closely with the Advisory Committee and in preparation for the launch of the workshop on the strategy, a technical group of experts was tasked to review the CMH report, prepare technical papers and adapt the CMH report recommendations to the Ghana context. The papers were to focus on health care, water and sanitation; they were to provide strategic options for scaling up investments in order to achieve high coverage levels with regard to sanitation, preventive and curative health care, and the quality of potable water. The targeted health interventions and per capita health expenditures were expected to AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

be comparable to those recommended in the CMH report. In conjunction with the Advisory Committee the Technical Committee provided evidence, outlined its findings and made provisional recommendations in technical papers. They suggested the following interventions: • Establishment of health insurance using the district-wide mutual health organization approach; • A pilot study of health insurance in the context of the Ghana poverty reduction strategy; • Implementation of communitybased health planning and services as the basis of a “Close to Client” (CTC) health system; • Waste management: a non- medical strategy for health; • Scaling up investments in community water and sanitation; • Scaling up urban water investments; • Mobilizing resources for scaling up health investments.

Official launching The activities of the advisory and technical committees culminated in the official launch of the strategy on 19 November 2002 in Accra, with President John Agyekum Kufour delivering the keynote address. This event was accorded the highest political priority by government as the function was attended by, among others, ministers and other senior government officials, parliamentarians, members of the Council of State, traditional authorities, the civil society, researchers, academics, development partners, members of the diplomatic corps, officials from WHO, the West Africa Health Organisation, and representatives of Nigeria and the United States.

Technical workshop and working groups A technical workshop attended by about 60 experts in finance, health care, water, sanitation, poverty reduction and related areas was held with the

main objectives of subjecting the draft technical papers to critical review, soliciting views and comments in order to improve the final output, and building consensus on the way forward for scaling up investments in health care, water and sanitation. Four working groups were formed in health care provision, health care financing, water and sanitation, and resource mobilization. Their outputs were incorporated in a separate report.

Activities A local expert synthesized the seven technical reports. The final report, identifies the gaps to be closed and has been developed into an advocacy tool, complete with an investment plan. The government is expected to budget for those activities which have been captured in the Medium Term Expenditure Framework (MTEF). To ensure that the recommendations of the final report are implemented, the following have been planned for: • Linking the strategy report to the budget through the MTEF process by ensuring that the recommendations are incorporated into the planning guidelines issued by ministries, departments, agencies and districts for the preparation of sectoral and district medium-term plans; • Revision of the PRSP using the recommendations in Ghana’s Macroeconomics and Health Strategy; • A round table discussion for relevant ministries, their chief directors, and other members of the Advisory Committee to sustain political support and continued advocacy; • Further consultations with stakeholders, including development partners and bilateral cooperation agencies, to build ownership and ensure consensus; • Presentations on GMHS to regional ministers, district chief executives and other political heads;

47

• Follow-up visits to targeted districts to ensure that GMHS recommendations are incorporated in their medium-term plans; • Sustaining the strategy and mainstreaming it into government interventions in health and health-related sectors;

tion of the technical papers. UNICEF, DFID, WHO and the World Bank also served on the Technical Committee. Due to their involvement and experience in the health, water and sanitation sectors, their technical contributions to the strategy have been invaluable. DFID provided some financial assistance to support the process.

• Development of monitoring and evaluation tools.

Challenges

Support from development partners Development partners and the diplomatic corps have been supportive of the GMHS. Their participation during the launch of the initiative was most encouraging. As members of the Advisory Committee, WHO, UNDP, UNICEF, DANIDA, DFID and the World Bank provided guidance during the prepara-

48

Sustaining the interest of all stakeholders in the process at all times has been a daunting task. However, the keen interest by the national coordinating unit and other key people in the various ministries, departments and agencies made it possible for participation to be sustained. Also, the ability to keep to the agreed timetable in producing the report is a challenge. This is due to the fact that the technical team members have their

full-time jobs and have to find time to support the work of the GMHS. Data is very paramount in the development of any meaningful document. In this regard, lack of data in certain forms and the accuracy of data available were other challenges that confronted the process.

* Mr D’Almeida is the Health Economist at the WHO Country Office in Accra, Ghana

AFRICAN HEALTH MONITOR JANUARY – JUNE 2005

Contact: Dr Joses M. Kirigia Regional Adviser, Health Economics World Health Organization Regional Office for Africa Cité du Djoué P.O. Box 6, Brazzaville Republic of Congo Tel: + 47 241 39000/39498; (242) 811409-812660 Fax: + 47 241 39501/39503; (242) 839503