The Harvard Ministerial Leadership Program

Transcription

1 The Harvard Ministerial Leadership Program In association with Big Win Philanthropy and with the support of the Bill and Melinda Gates Foundation Report compiled by Helene Perold and Dr. Reason Beremauro for Helene Perold & Associates Report on effects of the Ministerial Leadership Program as reported by ten Finance Ministers September 2017

2 Table of Contents Executive Summary Introduction Evaluation Methodology Findings and Analysis of Ministers of Finance Interviews... 8 i) The role of finance ministers in strengthening health systems... 8 ii) Finance ministers changing perspectives of their roles iii) Leadership in relation to strengthening the health sector iv) Collaboration between health and finance ministers to strengthen health sector performance v) Budget efficiency and effectiveness vi) Challenges in implementing effective and efficient use of health budgets Concluding observations

3 Executive Summary This report provides an analysis of the effects of the Harvard Ministerial Leadership Program drawing from the perspectives of Ministers of Finance from selected African countries who attended the Ministerial Leadership Forum for Finance Ministers between the years The analysis presented in this report is drawn from interviews that were conducted in June and July 2017 by the Principal Evaluator of the Harvard program, Ms. Helene Perold. A total of ten interviews were conducted with current and former Ministers of Finance from the following countries: Burkina Faso, Cabo Verde, Ethiopia, The Gambia, Liberia, Mozambique, Sierra Leone, South Africa and Tanzania. In the Gambia, both the former and incumbent Ministers of Finance were interviewed. The evaluation findings provide a deeper and nuanced analysis drawn from the participants specific contexts. The overarching goal of the Harvard Ministerial Program is to stimulate transformative vision, enhance leadership effectiveness and political acumen as well as develop planning and implementation capacity among ministers. This report specifically examines and highlights the ways in which these finance ministers goals and their collaboration with Ministers of Health (MoH) translated into systems, processes and outcomes for the health sector in their respective countries. The evaluation findings indicate that one of the fundamental principles ministers learnt from the Harvard Ministerial Leadership Program was the need to strengthen health systems in order to ensure improved health and human development outcomes. As a result of this understanding some of the ministers prioritized funding primary health care and embarked on initiatives to promote universal access to health care in order to ensure The Harvard Program helped me to see all the aspects of having a health system in which primary care is one of the first pillars. And that was that fact that you can have an impact on economic growth, on workforce productivity and also have a very good impact on the value chain on expenditure in the health sector. Finance Minister 2 2

4 that the health sector supported development and economic growth within their countries both in the short and long term. The Harvard Program changed ministers perceptions about their leadership roles and strategic functions. The findings indicate that the ministers embraced greater accountability responsibilities and in turn they held other ministers accountable for budget allocations. Some of the ministers changed the way they led their ministries and they implemented notable changes such as adopting results-based systems and approaches in conducting government functions, duties and responsibilities. In instances where both finance and health ministers participated in the Harvard Program there was greater synergy and collaboration between them, and this understanding produced better outcomes than in cases where only the finance minister had attended the Program. The closer collaboration between the finance and health ministers enabled the ministers to articulate and better support plans, procedures and systems for their health sector priorities. The findings show that these finance ministers sought to increase fiscal space, curb wastage, cut costs, and generate revenue measures that collectively aimed to improve health budget efficiency and effectiveness. In cases where some of the finance ministers failed to achieve their targets there were external factors that The Harvard Forum is an eye opener, in terms of how the budget can be executed, where resources are properly reallocated, and you can achieve maximum results. Finance Minister 6 hindered them such as emergencies, electoral processes and cabinet reassignments. Among some of the notable systems, processes and outcomes introduced by the ministers are the following: results- and performance-based systems of budgeting and resource allocation; the creation of management teams within cabinet:;and setting up new management systems with regular reporting and monitoring mechanisms. Newly introduced processes included the prioritization of health programs and activities; the allocation of resources to ministries that supported the health sector; changing procurement systems; and upgrading health facilities in 3

5 order to curb the use of foreign currency in overseas medical institutions. Some of the key outcomes include the audit of a health payroll; changes in procurement systems; and the optimization of health expenditure. Collectively, these systems, processes and outcomes contributed to the strengthening of the health care systems in the different countries. 1. Introduction This report provides an analysis of the effects of the Harvard Ministerial Leadership Program drawing from the perspectives and experiences of ten Ministers of Finance from selected African countries who attended the Ministerial Leadership Forum for Finance Ministers between the years The Harvard Program was initiated in 2009 and is a joint initiative of the Harvard T.H. Chan School of Public Health, Harvard Kennedy School and the Harvard Graduate School of Education. The overarching goal of the Program is to stimulate transformative vision, enhance leadership effectiveness and political acumen, and develop planning and execution capacity among ministers from Africa, Southeast Asia, and Latin America. Ministers are invited to participate in the Program based on the leadership capabilities they demonstrate in their respective countries. This report is part of a three-year independent evaluation of the Harvard Program and it provides a detailed analysis of interviews conducted with the ten Ministers of Finance (MoF) who attended the Ministerial Forum in different years. Specifically, the analysis seeks to address the broad question of how the finance ministers goals and their collaboration with Ministers of Health (MoH) translated into systems, processes and outcomes for the health sector in their respective countries. The analysis pays particular attention to how the ministers plans and initiatives aimed to strengthen health systems to ensure improved health outcomes. The section below outlines the evaluation methodology including the selection of the Ministers who participated in the evaluation. 4

6 2. Evaluation Methodology The material presented here is drawn from interviews conducted during June and July 2017 by the Principal Evaluator of the Harvard program, Ms. Helene Perold. A total of ten interviews were conducted with current and former Ministers of Finance from the following countries: Burkina Faso, Cabo Verde, Ethiopia, The Gambia, Liberia, Mozambique, Sierra Leone, South Africa and Tanzania. In The Gambia, both the former and incumbent Ministers of Finance were interviewed. All these ministers attended the Harvard Ministerial Forum at some time between 2014 and The participants were selected purposively taking into account factors such as the year of the Forum they attended, the duration of their stay in office, gender and their availability for interviews. Another important criterion was the portfolio or capacity the Ministers were serving under at the time of the interview, either in government or any capacity outside of government. Of the ten ministers, six are still in office as finance ministers whilst the other four are former ministers. There were seven male and three female participants. The selection criteria enabled the Evaluator to draw on a range of experiences from diverse contexts, and collectively the combination of both former and serving ministers provides the opportunity to examine the relevance of the Program to both the serving and former ministers. The selection criteria had some inherent weaknesses that might have inadvertently affected the evaluation approach. The Ministers attended different Ministerial Forums and they had spent differing periods holding the finance portfolios. Some of the participants attended the Forum in April 2017 and due to the relatively short intervening period between their return from the Forum and the evaluation interviews, some of them had not fully implemented the principles from the Forum or fully realized the outcomes of their initiatives. In some instances the respondents had been moved to different ministries or spent relatively short periods within the Ministries of Finance and in such cases the impact of their initiatives, particularly in terms of the outcomes, are difficult to decipher. The Evaluator however mitigated 5

7 this weakness by inquiring how the informants were applying the principles they learnt in their new portfolios or roles. In a way, this speaks to the broader impact and utility of the Program in enhancing leadership capabilities beyond strengthening health sector performance. In cases where the participants were no longer holding government positions, the interviews offered them a platform to share richer reflections of their time in office without the strictures of government office and this in some ways enhances the quality of the findings and analysis provided in the report. The evaluation process was also affected by the fact that some of the informants were either moved from the finance ministry through Cabinet reshuffles or lost their positions following elections. In such cases, the outcomes of their initiatives as well as the impact of changes they instituted are not obviously apparent. The findings and analysis presented in this report should be contextualized and understood within the broader contexts the different participants are located. The implementation and application of certain principles and approaches was, at times, mediated and impinged upon by circumstances outside of the finance ministers immediate control. Such factors included economic recession, which directly affected resource mobilization and allocation. In the case of some of the West African countries, the health systems were severely affected by the Ebola virus which placed a massive strain on infrastructure and budget allocations. While these circumstances affected the finance ministers abilities to plan, it also enabled them to demonstrate political acumen and leadership effectiveness in difficult circumstances, and the report attempts to bring out these qualities and abilities. The analysis presented here is not generalizable to the countries whose ministers participated in the Program; rather its main aim is to provide detailed insights drawn from the perspectives and experiences of the ten key informants. In the report the ten ministers are referred to as key informants, participants, ministers or respondents and these terms are used interchangeably. 6

8 The questions posed to the ten respondents are listed below: 1. How did your participation in the Harvard Program impact on your role as finance minister generally? More specifically, do you think you were a more effective leader after participating in the Harvard Forum? If yes, how specifically were you more effective? 2. The Program encourages health and finance ministers to collaborate to strengthen health sector performance. Were you able to collaborate with the health minister? If so, what results did this produce? If not, why not? 3. The Program places a strong emphasis on health budget effectiveness and efficiency as a driver of health system strengthening (e.g. increasing fiscal space in the health budget through budget reallocation, cost savings, efficiency, increasing domestic revenue, public-private partnerships). Did the Program have any impact in helping you leverage health budget effectiveness and efficiency to improve health system performance? How specifically? 4. Please describe TWO or more specific initiatives arising from your participation in the Harvard Program that you have implemented. How would you describe the enduring impact of these initiatives? 5. [Asked in the case of seven countries that participate in the follow-up component of the Program.] Regarding the participation by the joint health-finance Senior Leadership Team in the follow-up support provided by the Program: Did this have any tangible benefit to you in implementing your key priorities? How specifically did the Team contribute to implementation of your priorities? 6. Reflecting on your term in office, how would you describe the enduring value of your participation in the Harvard Program? Would your record in office have looked any different if you had not participated in the Harvard Program? 7

9 3. Findings and Analysis of Ministers of Finance Interviews This section presents the analysis of the interview material. The data show how these ministers participation in the Harvard Program affected their perspectives and roles as finance ministers, particularly in their engagements with the ministries of health. The analysis also explores the ways in which these finance ministers responded to the notion of collaboration with their health ministers to improve value for money and achieve better health outcomes, and whether they extended The Harvard Program approaches beyond the health sector. The material analyzed here also details the initiatives the participants undertook to mobilize resources and whether the resources were used more effectively and efficiently to strengthen health sector performance. The main thrust of the analysis is to highlight how the Program goals, principles and approaches were translated into systems, processes and outcomes, and how these impacted on or enhanced the performance of the health sector and affected the actions of the health ministers. In the first instance and in the subsequent section the report focuses on how these finance ministers learnt about the importance of strengthening health systems to produce improved health outcomes. i) The role of finance ministers in strengthening health systems In the interviews the respondents highlighted that a key principle they learnt from the Program was the need to strengthen health systems in order to ensure improved health outcomes. The ministers stated that the Program emphasized how the health sector was imperative in a country s development and how they could achieve success and value for money in financing health care through prioritizing Primary Health Care and universal access to health. Six out of the ten ministers stated that they had prioritized Primary Health Care and universal access to health care and they viewed affordable and accessible health care as important to development. 8

10 A relatively new finance minister (Minister 5) stated that he now understood the need to create an affordable health care system, and that his role was to prioritize the health sector and restructure the administrative systems so as to ensure health care was affordable. He stated that his target was to: work through the budgeting to make sure things are in line with the needs and the health policy to have an affordable healthcare system. The interview material highlights that there are various ways the ministers sought to establish such affordable and accessible health care systems. For example: Finance minister 2 revealed that through participation in the Forum she came to appreciate the need to invest in primary health care, because doing so not only strengthened health systems in her country, but offered value for money in the long term. She came to the realization that primary health care would undergird her country s economic wellbeing through providing a much more productive workforce as well as lowering expenditure in the health sector in the long run. Her country structured national health systems in such a way to give the necessary relevance to primary care. She stated that : We managed to implement a health system in which the primary care is an important one. By following the Harvard Program, it became clear that I was doing better from an expenditure optimization standpoint. The Harvard Program helped me to see all the aspects of having a health system in which primary care is one of the first pillars. And that was that fact that you can have an impact on economic growth, on workforce productivity and also have a very good impact on the value chain on expenditure in the health sector, because when you invest more in the primary care, down the road you will of course use your financial resources more efficiently. So for example, if for ten years you invest in primary healthcare, this is a long term investment. Short term strategy does not work for this approach. Former health minister 9 stated that after his participation in the Program he prioritized universal health care through both the development of a National Health Insurance (NHI) policy as well as promoting a coordinated approach to health care provision through improving health services offered in public facilities: 9

11 With universal health, we have this platform that we are talking about you need to pool resources, you need to improve the quality of the public health facility such that people don t have to run to the private facilities in order to get a better service. So you need to improve the quality of service in those. But you also need a legislative framework like we have got the NHI policy in place. So you do need universal access as well, but you do need a coordinated approach with the private sector playing a role together with government to promote such a coordinated approach. Respondent 6 revealed that his participation in the Program strengthened his resolve to be a transformative' leader and in his case this partly took the form of prioritizing primary health care. Within prioritizing basic health care, he aimed to make an impact on the most critical aspects: What do we look out for in the case of the country s healthcare system? Do they have issues of maternal mortality rate that are very high, do we have a situation of infant mortality rate that is also high, then the question is yes, in terms of an answer, for which the resources must be targeted in a way that says, can we strengthen the healthcare system in a way that addresses mortality rates, be it for maternal, be it for infants? So in that way, we can rather take money and put it where the maximum results are needed rather than say, oh in healthcare, can we focus on all of the issues. Do we need more of polio vaccine or do we need more of healthcare results in the area of reducing mortality rates related to mothers and infants? So it is that sort of way of achieving in obtaining what is best needed for our setting. Following their participation in the Harvard Program, ministers appreciated the importance of the health sector in their respective countries development. Some of these ministers actively financed primary health care systems and promoted access to universal health care in recognition of the important role the health sector played in development. ii) Finance ministers changing perspectives of their roles All ten participants stated that the Harvard Program was useful in changing the ways they perceived and understood their leadership roles as ministers of finance as well as the role that the finance ministry plays - not only in fostering economic development, but in strengthening health sector performance as an essential investment for economic growth. In practical ways, respondents highlighted that 10

12 after participating in the Program s Ministerial Forum, they began to prioritize their goals in a much more focused manner. They also changed their perception of health ministry spending - from consumptive units to a sector requiring investment. Finance minister 3, currently in office, stated that the value of the Program lay in the manner it improved his understanding of performance management, particularly the importance of setting priorities: I can now make a list of priorities that are a significant conclusion to policy goals that we have set. So prioritizing tasks and mobilizing my staff around these priorities, focusing more on implementation and results. It has been more results driven, focus oriented. Following his participation in the Program this minister revealed that he had changed the planning process in government, and instituted a monitoring system that tracked progress in different sectors. In this country the Harvard Program thus had an influence that extended beyond the Ministry of Health to other ministries, through the new monitoring system introduced by the Ministry of Finance: I have changed the annual planning process. Now we have an action plan for ministries. It is focused and clearly sets the key priorities for the year. We have indicators and milestones. I have also put a clear system for monitoring progress, performance and results. So the monitoring system is the focus right now within my ministry. Finance minister 8 stated that the Program reaffirmed what he previously believed, which is that sectors such as health and education should be prioritized in resource allocation, as these are essential for human development: The Program was [helpful to] refocus attention, maybe narrow in specific areas, which are critical to the progress of one s society - focusing on education, focusing on health, making effort to make substantial [investment]. But for me personally, this was just a reinforcement of what I believe, of how I think we should approach development. 11

13 As a result of his participation in the Harvard Forum, he stated that his ministry introduced legislation to institutionalize a new way of conducting business, especially to help ministries prepare budgets, prioritize key areas of expenditure, and discourage resorting to supplementary budgets except for emergencies: Well, you know historically, the Ministry of Finance had evolved itself into a super ministry. Since I came in, we have pushed in the Public Financial Management Act (PFMA), which is going to replace the Government Budget and Accounting Act. We now have a new way of doing business and one of the challenges is helping ministries to prepare realistic budgets because of the notion of priority; we are now working on the rules and regulations. The notion of extra budgeting is out - except for absolute emergencies like we had with Ebola or like if we have an earthquake or storm. You have to get your priorities right. If you have five priorities, rank them. All ten finance ministers stated that their perceptions of the role of the Ministry of Health (MoH) was changed or transformed during their participation in the Ministerial Forums. Prior to their participation in the Forums, a widely-held view among the participants was that health ministries were consumptive in that they made little if any contribution to economic development. After attending the Ministerial Forum, these perceptions changed completely: in all the ten countries, financing health care was increasingly perceived as a necessary investment for development. The participants changing perceptions of the health sector resulted in them changing their leadership styles and engaging their health ministers. For example, former finance minister 4 stated that the Program changed his perception of the health ministry, and this resulted in him changing the manner he engaged and interacted with officials from the health sector: I think the Program has been very useful certainly because one, I have learnt new things and, two, the participation has improved my understanding of the health sector and also therefore increased my participation and interaction with the health sector personnel. The perception I used to have [of the Ministry of Health] has changed significantly from how I used to see them before the Program. Initially, you see them more as people who want to spend money for the sake of spending. But after participation in the Forum I got a better understanding of what the health sector is all about and how as the Minister of Finance I can participate in ensuring 12

14 better outcomes improvement with the resources that have been allocated how to strategically and effectively use those resources. Certainly before that [participation in the Ministerial Forum convened at Harvard University], health was seen more as a spending unit and we were not seeing it in terms of its contribution to economic growth. Former finance minister 4 s views resonated with those of key informant 9, also a former minister, who highlighted that resources spent on health (as well as education) were a form of investment that improved the quality of life for citizens: The understanding that health and education - always take the two together: that is where you always find almost all of our HDI indicators. So it is an investment, but of course there are other competing needs but it talks to a broader program of improving the quality of life of people in terms of life expectancy, looking at literacy, looking at child mortality, and stuff like that. So all of those things you begin to realize that unless we have some understanding of where we fit them in the broader government agenda, we have the tendency of just talking resources. Finance minister 1 s views about her participation in the Harvard Program are particularly instructive and resonate with the views of the other participants. The Program enabled her to see resource allocation to the health sector as a form of investment, and that as the Minister of Finance she could also engage in discussions around the health sector especially on how to invest more strategically in the health sector: In the past people used to consider that ministers of finance do not need to be involved in discussions on the health sector. It was considered [a domain] for medical doctors; but due to my participation in the Forum in Harvard, I began to engage in very interactive and productive dialogues with my colleagues in the Ministry of Health. Particularly, it is not only about saying that health is expensive, but it was about saying that if we invest in health we will get a return on our investment. It was also the demonstration that investing in health can also give us a long-term development perspective in our country. Number three, with the exchanges with peers, it also gave me the opportunities to see that we can invest more strategically in the health sector. It is not about spending more money. It is about spending better money with very good services etc. One of the participants, former finance minister 10, revealed that her participation in the Harvard Program led to a greater understanding of the importance of 13

15 financing the health system, and ultimately this led to health reform in her country through the introduction of national health insurance in order to extend access to health care services to all the communities within his country. She stated that her leadership was instrumental in the introduction of a national health insurance program, which she sees as her legacy: My participation in the Harvard Program made me realize how important health financing could be for the wellbeing of the people and for the economy at large. The healthier the population the more the economy grows- at least that is the hypothesis. It made me participate in ministries of health inner programs. It even came to a point where as a government we realized how important it is for the people to have access to better health services. The government is in the process of ensuring that all the people in the communities have health insurance which I could also say was part of my intervention. Now we are in the process of ensuring that every community in the villages and in towns has health insurance. I am very proud of that because I also contributed to that- to the thinking and to the reform - it was because of my participation in the Harvard Program. For respondent 8 the Harvard Program s focus on education and health affirmed what he perceived as critical priorities in society, but from the Program he learnt to manage competing demands and to prioritize these two areas as key investments into human resources: Well you know the Program was helping you like refocus attention, maybe narrow in specific areas, which are critical to the progress of one s society - focusing on education, focusing on health, making effort to make substantial - what you call down payment for your house. Then the leadership from that point becomes how you manage it, because you face naturally as Minister of Finance, fiscal demands all over you and you have to sit down with the staff and make a case for putting more money always in education, putting more money in health. But for me personally, this was just a reinforcement of what I believe, of how I think we should approach development.i think the course allowed you to - for me personally - reinforce your belief, how to spend money, how to invest in your human resource because at the end, that is really what you have. While many of the participants began to see health care as an investment rather than unproductive spending, one of the ministers, respondent 3 saw his role broadened to improving the efficiency and effectiveness of the public financial 14

16 management system in the country within public entities, mobilizing resources and applying prudent financial systems: So one is improving efficiency and effectiveness of government budget. Broadly, I am trying to strengthen the public financial management system in the country with the objective of improving budget efficiency allocated to the different parastatals. That is the key priority. Then I am responsible also for administering fiscal policy, so creating a prudent fiscal system that supports inclusive economic growth, through mobilising resources, tax revenue and other resources to support our development programmes. In general the interview material shows that the MoF s participation in the Harvard Program changed their perceptions of their leadership roles within the government and their countries at large. These changing perceptions also transformed their leadership and strategic roles. The section below examines the ways in which the leadership responsibilities of the Ministers changed and the manner this change impacted on their respective countries. 15

17 iii) Leadership in relation to strengthening the health sector According to the interview data, the finance ministers leadership roles in relation to health were affected as a result of their participation in the Program. All ten key informants revealed that the Program helped them to perceive their responsibilities as encompassing the need to demand greater accountability from fellow ministers. Significantly, their participation helped change the way they led their ministries, and it also changed the ways in which they understood their strategic roles as Ministers of Finance. Among some of the changes the participants initiated was the adoption of a results based approach in carrying out government functions, duties and responsibilities. A key output in three countries was the realization of the importance of national health insurance policies and in two of these three countries processes for the establishment of national health insurance policies were initiated to extend the provision of universal health care. The interview material shows how the interviewees leadership and strategic roles varied, depending on what they perceived as key priorities in their specific contexts. This section casts attention on what the ministers did in order to strengthen the health sector. Participant 5 stated that the Program was essential in enabling him to work towards the development of a new economic policy, the National Development Plan ( ), creating management teams within Cabinet as well as setting up new management systems that included holding regular meetings, instituting reporting systems and mechanisms, and introducing performance evaluation for staff: The Program broadened my vision on how to work as a finance minister and [with] the rest of my Cabinet ministers to get the economic transformation that they are looking for. Right now we are developing our national development plan for At the ministerial level in terms of leadership, we have been able to build a management team. Previously there were no such meetings [between ministers and] permanent secretaries and directors. Now we have monthly meetings. We have monthly reporting as well and we are developing performance targets and we will develop performance evaluation of staff. So [the Program] has changed the 16

18 work culture of the ministry and the staff is adjusting to that. I think it is more effective than the previous set up that I found here. For Finance minister 6 the value of the Program was in its ability to strengthen the health system not just through directly financing the health sector, but through reallocating resources to other sectors in a manner that supports and strengthens health care such as improving access to clean water and sanitation for communities. He revealed that: In the area of healthcare, especially on the watch is water and sanitation. What are the issues there? We have close to 60% of the population that doesn t have access to good drinking water, don t have better access to sanitation facilities in terms of toilets. There is a need to improve - so it is in that context that the strategic focus of resource allocation must be address specific needs as a country. So that ends just here. So my situation is a combination of infrastructure, health and education. So those are the three focal areas. One of the former ministers, respondent 9, also saw his role of finance minister as one of making strategic allocations to other ministries, such as those of education and social development, whose programs directly and indirectly support the health ministry. He also pointed to the importance of investing in employment. The approach he adopted had wider applicability beyond the Ministry of Health, and would support the priorities of the health minister: At times people just think that it is the allocation of resources that will solve problems and yet in most cases it is about making sure that the resources are spent efficiently, are spent in areas where they would have the greatest of impact. If you look at our resources in this country you will realise that health has one of the largest budgets. But all in all, I think it is important to always have a fuller picture, so that when you are allocating resources in health, you are not just allocating them in health but also allocating in other departments that work closely with the Department of Health. I have mentioned education. Social development is also one of those, but also investing in areas that create employment, because in the absence of that, you have people that are not in a position to be able to afford healthcare. During his time in office as the head of Treasury, the minister contributed to the development of the National Health Insurance policy (NHI). 17

19 Finance Minister 6 said that the Harvard Program enabled him to see his role as that of demanding greater accountability from other government ministers as a means of improving budget efficiency and overall performance: In the context of performance when you are coming to us, you have to come with your report in terms of what was achieved from the previous allotment made to your given sector. So the activities you implemented, what were the outcomes - that sort of performance-based, sort of grading of your performance is what will inform us of how we are making additional allocation to your ministry or a given sector. Finance minister 8 revealed that in his country the finance ministry went beyond resource allocation to holding other ministers accountable in a manner that curbed wastage for example, by cleaning up the health payroll and reallocating the savings made to areas of need. The Minister of Health easily bought into my project proposal because I sat down with him and his staff and I asked my accounts people to print the whole payroll. I literally sat down with him, as well as the the Chief Medical Officer and went through some of the payroll and realized that we needed to substantially clean the payroll, which was essentially one of the projects I was proposing - to the effect that if we clean the payroll, the money saved can be ploughed back to more effective use of the Ministry of Health - it could be a better way to utilize the Ministry of Health resources. So in fact, even as I sit here, this is one of the four things in my mind to put up a program to clean the payroll - I don't think that payroll is real. Finance minister 1 revealed that her country was allocating resources to achieve specific health outcomes despite the scarcity of resources. In this case resources were allocated to support reproductive health for young women: [In the] new budget that we have prepared for 2018, my hope is to see that it is very result oriented in the health sector. And the good news that I also want you to know, [country 1] here in our region has earmarked for 2017, 500 million local Francs which is about 1 million in USD to invest to reproductive health, because we have realized that despite the scarcity of resources, we see that investing in health, particularly in the health of young women, we will really get value added in the development of our country. 18

20 In general these ministers and former ministers demonstrated leadership and political acumen through supporting the introduction of national health insurance policies that would extend health care access and ultimately improve and strengthen the health delivery system. The participants also began to hold fellow cabinet ministers accountable for budget allocations in order to promote fiscal discipline and increasing the fiscal space. In the section below the report details how Ministers of Finance collaborated with Ministers of Health as well as other ministers, and in what ways some of the principles and lessons learnt at the Harvard Program were applied to such collaboration. iv) Collaboration between health and finance ministers to strengthen health sector performance A key observation that emerges from the interviews is that after attending the Harvard Ministerial Forums, these finance ministers engaged and collaborated with their Ministers of Health as well as other Cabinet ministers. In countries where both the Ministers of Finance and Health attended the Program, there was increased collaboration and synergy between the participants and their ministries, and this was beneficial particularly in enabling them to devise their plans, and articulate more rigorous procedures and systems. Nine out of ten interviewees stated that their collaboration with their health ministers was productive, and helped them to achieve their goals. For three respondents these outcomes included introducing the national health insurance programs, reforming procurement systems, and creating priority lists that channelled resources to areas of greatest need. In one case the finance minister did not manage to collaborate with the health minister because of a Cabinet reshuffle, and at the time of the interview the two ministers had not yet met. One finance minister collaborated with his health 19

21 counterpart, but encountered resistance from officials working within the public administration structures who struggled to adjust to reforms. Finance minister 3 stated that after attending the Harvard Ministerial Forum, he started collaborating with the health minister and a key outcome that emerged from this collaboration was the drafting of a social health insurance system: We started collaborating with the minister of health. We actually decided to focus on the newly launched social health insurance system. The government just drafted a policy introducing a social health insurance system. Myself and the minister of health agreed that I can introduce some of the things I learnt at Harvard in the social health insurance. Key informant 4, a serving finance minister, stated that the finance ministry s collaboration with the health ministry precipitated changes to the procurement system in order to make it more efficient and effective. In collaboration with other government partners, he proposed a change from a single source procurement system to an international competitive system. The ministry of health was able to list the essential drugs the country needed and it is anticipated that these changes will improve access to drugs and health care: We are beginning to collaborate. The health sector faces numerous challenges, very difficult challenges in the procurement system and the distribution system of drugs throughout the country. So we really want to support them to change the procurement system to make sure it is more efficient and effective. So currently with the World Bank also insisting on it, we were able to change from single source procurement to an international competitive system. [The health ministry] were also able to come up with a list of essential drugs. But still the challenges are numerous. Right now resources are limited - so that really increases difficulties in solving these challenges. But the collaboration has begun and we really look forward to changing the health sector with the primary health care system, and improving access to drugs. With the previous regime everything was order, command and directives. So that is why we had single sourcing entrenched in it. We are beginning to pull together again to have an impact. In the case of former finance minister 2, her participation in the Program produced a much stronger relationship with the Minister of Health, which ensured that they had 20

22 common goals, and better articulation of their efforts in managing health expenditure whilst optimizing health revenue. While in office and for two successive years she managed to increase the health budget while the ministry of health managed to eliminate wasteful expenditure: The best results as Minister of Finance at the Harvard Program has been the fact that my relationship with the Minister of Health has been much better organized and together we have been able to work in such an articulated way having a common goal in our health expenditure, but at the same time trying to optimise health revenue. We have been able to do a sort of agreement. So I would try to increase the health budget, no problem; but at the same time, the Minister of Health had to prove that she managed the same budget more efficiently and in a more optimized way. She implemented all reforms. She was able to eliminate wrong and bad expenditure. She was able to optimize health expenditure. At the same time, the budget of health has been increased twice in 2014 and The Program put us together in the same analytical framework with a very strong monitoring by the Harvard University, and more than that working together in a team approach. In participant 9 s country where both the finance and health minister attended the Program s Ministerial Forum, the former finance minister observed that there was greater synergy and cooperation between his ministry and that of the health ministry. The finance minister stated that: I found that we were more in sync than we were before I went. Indeed we had a good working relationship even prior to that, but we were much more in sync because he had also attended the one for health ministers. That helped a great deal. And I think in our processing of position papers, we were very much aligned than we were prior to the Program. We exchanged experiences; that is where we enriched each other s understanding. The interviews show that although most of these finance ministers collaborated with their health ministers in ways that produced some favourable and positive outcomes, some also had to contend with instances of resistance, particularly from the wider political sphere. For example, in country 2 the former finance minister stated that reforms she instituted to bring about accountability and efficiency were initially resisted, because of her insistence on greater transparency, efficiency accountability and control: 21

23 I faced strong resistance because the expenditure side of the reform was guided by more transparency, more accountability which means more control. Let me give you an example: Before, all school budgets for each school was out of the budget. During my time and because of the reforms, all budgets for schools were fully integrated [into the budget]. Since I developed a strong technological platform, expenditure was processed within the system - not manually, but within the system following five steps. These five steps involved the sectoral ministry and the last three financial ministers, and thousands and thousands of staff from public administration. As you can imagine, these are kind of reforms people do not expect very quickly. So I met strong resistance not because they did not participate in the Harvard Program, but because the reform changed a lot transparency, accountability, efficiency. Maybe this type of work if it could involve more ministers could be helpful. In the one instance, finance minister 3 said that although he had not yet been able to collaborate with the health minister due to a Cabinet reshuffle. In this particular case the former health minister had attended the Forum in 2013 and officials from his ministry attended a suppport workshop thereafter. The Minister of Finance then attended the Forum in 2015 and worked closely with then Minister of Health, particularly in drafting the social health insurance policy. A cabinet reshuffle resulted in the departure of this particular health minister in February Although the serving minister of health has not shown much support for the Program, the interministerial technical committees drawn from both the finance and health ministries are working together: There is a new minister [of health]. To be honest we have not talked about it. In fact there is a joint team with two senior experts from the ministry of finance and ministry of health working around those areas [of collaboration]. We have not elevated it to ministerial level, but the technical committees are working. In general in instances where the MoF collaborated with the MoH there were positive outcomes that resulted in the optimization of the budget and reduction of wasteful expenditure. In some instances ministers were also able to formulate policies that facilitated the introduction of national health insurance that would in the long term extend access to universal health care. Some of the systems introduced include results- and performance-based systems of budgeting and 22

24 resource allocation, the creation of management teams within cabinet and the setting up of new management systems with regular reporting and monitoring mechanisms. Newly introduced processes included the prioritization of health programs and activities, the allocation of resources to ministries that supported the health sector, changing procurement systems and upgrading health facilities in order to curb the use of foreign currency in overseas medical institutions. Some of the key outcomes the audit of health payrolls, changes in procurement systems and the optimization of health expenditure. The following section examines the ministers initiatives to utilize health budgets more effectively and efficiently in order to strengthen health care systems. v) Budget efficiency and effectiveness In this section the report details the ways in which the finance ministers sought to encourage the more effective and efficient use of health budgets in order to strengthen health systems in their respective countries. The focus is specifically on how these ministers sought to increase fiscal space, curb wastage, cut costs, generate revenue, and whether these measures improved health budget efficiency and effectiveness. The interviews indicate that six out of the ten participants derived tangible outcomes from applying the Program approaches, even though they were confronted by challenges and hindrances. The other four participants subscribed to the principles taught in the Harvard Program and had implemented these approaches, but by the time interviews were conducted, the outcome of their efforts was largely inconclusive. Finance minister 5 said that his country sought to use the health budget more effectively and efficiently by adopting new systems, procedures and processes particularly in health procurement systems. The participant stated that: 23

25 I think the Program will improve and increase the sectors efficiencies. The budgeting will try to prioritize health programs and activities. In the implementation we cut down waste through competitive procurement, stress management and distribution to the different health clinics in the counties. So we will work through the budgeting to make sure these things are in line with the needs and the health policy to have affordable health care system. While this finance minister was introducing reforms, particularly pertaining to the health procurement systems, the outcomes of the reforms are not immediately obvious due to the relatively short period he has been in office (since February 2017). Former finance minister 4 revealed that his country sought to mobilize domestic revenue to support the health care system through introducing a system of increasing taxation on tobacco annually: In terms of additional resource mobilization, one that is very clear is taxation on tobacco. When we came back [from the Forum] I said: one way to raise money is to initiate taxes on tobacco. When I mentioned this to the health minister, he said in fact there is a United Nations framework convention on tobacco control and he said to me it has provisions along those lines. I said look at it and come back with a proposal that we will be implementing on an annual budget. That has happened. Every year when you listen to the government budget, there are new taxes on tobacco that are implemented. I think that is something that I am proud of. The tax on tobacco used to be there, but not on a regular basis. But after the Program, it was institutionalized. Every year, there would be a new tax [on tobacco]. Since we cannot say we are banning tobacco imports, the best thing was to do taxes on an annual basis until we have reached a point where tobacco use has been brought to a minimal level. Finance minister 8 said that issues of budget efficiency and effectiveness were being addressed through upgrading two hospitals into specialized units offering high medical care and in the process saving the country s foreign currency reserves by dissuading people from traveling abroad to seek medical care that is unavailable in their country. The finance minister viewed this as an investment in health care so as to realize savings on the country s foreign reserves while simultaneously strengthening its health delivery system: 24