Ministerial Forum for Finance Ministers

Transcription

1 Ministerial Forum for Finance Ministers Harvard University April 7 0, 06 In association with Big Win Philanthropy and with the support of the Bill and Melinda Gates Foundation EVALUATION REPORT Analysis and compilation by Helene Perold and Aislinn Delany with Jacques Perold for Helene Perold & Associates

2 Table of Contents. Introduction.... Overview of evaluation findings.... Evaluation methodology.... Competency profile assessment.... Changes in group feedback on self-reported competency levels.... Pre- and post-forum impact: Net confidence ratings Changes in individual feedback on self-reported competency levels... 9 Country... 9 Country... 0 Country... Country... Country... Country 6... Country 7... What is likely to change? Impact on ministers leadership role Health as a priority for national development Impact on the finance minister s job Challenges Collaboration between finance and health ministers....6 Other responses... Annexure Ministerial Forum for Finance Ministers Program... Annexure Day Feedback Report... 8 Annexure Day Feedback Report... 7 Annexure Day Feedback Report... 8

3 . Introduction The annual Ministerial Forum for Finance Ministers is a core part of the Ministerial Leadership in Health Program at Harvard University. The main goals of the Forum are () to enhance ministers understanding of national health as a cornerstone of economic development and sustainable growth, and () to provide analytical tools and practical ideas for improving standards of public health care and health outcomes by achieving greater efficiency in health resource utilization. Nine finance ministers attended the 06 Finance Ministers Forum from April 7-0, 06. The ministers came from the Bahamas, Bhutan, Burkina Faso, Ethiopia, Gabon, Guinea-Bissau, Guyana, Mozambique and Sri Lanka. A real-time evaluation process was conducted over the four days of the Forum in order to assess the extent to which participants felt they had gained useful knowledge and skills, and how well prepared they felt to implement these skills after they returned home. This report outlines the learning recorded by each of the participants over the course of the four days. It documents how they rated changes in their knowledge, and reflects their self-assessed competence levels to support health sector strengthening.. Overview of evaluation findings The evaluation results demonstrate that the Ministerial Forum for Finance Ministers made a major impact on the participants in four key areas: I will be able to implement the plans outlined and have a legacy of increased fiscal space through the introduction of VAT. (Country ) It strengthened their leadership capabilities, particularly with regard to importance of health sector performance for economic growth; It changed ministers attitudes to the health sector and convinced them of prioritizing investment in primary health care; It changed their perspective on health financing; and It gave them the practical tools to strengthen the delivery of policy goals. We know how the budget can be allocated to make sure that we have value for money and also value for many. That is a new concept. (Country 7) The Forum succeeded in increasing confidence levels across all ten competencies measured at the start and end of the process. By the end of the Forum, all the finance ministers felt equipped to advocate for investment in health as a pillar for economic growth and national development, and all but one (86%) felt equipped to back this up by developing a health budget decision-making framework, and increasing effective and efficient health budget utilization (see Figure ). More than two-thirds of the ministers ended the Forum feeling well equipped to identify fiscal space in the health budget, structure a public sector funding package for health, and monitor outcomes. Just more than half the ministers (7%) felt confident to hold the minister and officials accountable for health sector performance. The competencies associated with increasing value for money in health, and increasing private sector involvement in public health, recorded the lowest confidence levels by the end of the process.

4 Figure : Post-Forum Net Confidence Ratings (n=7) Health financing was the area in which the participants made the largest gains, having felt least equipped for these competencies at the start of the Forum (Figure ). The ministers recorded considerable increases in knowledge and confidence on how to utilize the health budget more effectively and efficiently, identify fiscal space in the health budget and, using the delivery approach, strengthen accountability for health budget effectiveness and efficiency. Figure : Pre- and post-forum competence profile: Group average (n=7) Net confidence ratings show the percentage of participants who, by the end of the Forum, had developed high confidence levels (feeling well equipped ) to implement different competencies associated with the role of Finance Minister. Given the small number of respondents (seven in this case), the net confidence increases should be regarded as indicative of the impact of the Forum.

5 How will the Forum impact on the ministers jobs? Two ministers said they need to get more involved in the detail of budgeting for health. Another intended restructuring his Sometimes we fall into the trap of just adding a percentage into the budget, but what this assures me is we really need to go and see what it is we are trying to achieve and look at specific outcomes redirect more money to it, and put in performance measurement. (Country 6) management team and focusing on goal setting, while a fourth mentioned that she would apply her new-found skills in getting her team to see health in a new light and produce a very focused mid-term plan. Sustainable financing for health care remains one of the key challenges, as is the task of improving health service delivery in contexts where the population is thinly spread. Some ministers felt positive that the approaches discussed at the Forum could provide a way of navigating this difficult terrain, but one minister was concerned about the feasibility of implementing the health financing approaches in his country where health services and education are delivered free of charge. Most of the finance ministers were positive about the prospects for collaboration with their health ministers, particularly because this would work to their benefit. One said that strengthening primary health care would in the long term help him save costs associated with non-communicable diseases; another said that the Forum had convinced him to become more involved in budget formulation with the sectoral ministries (especially health) because this would enhance his effectiveness as finance minister and give him more control over budget prioritization.. Evaluation methodology As was the case in previous years, the evaluation process was designed to track the development of participants knowledge, skills and confidence, and to provide the Harvard team with daily feedback about the program content, presentations and discussion. Specific aims of the evaluation process were as follows: a. Provide comparative self-reported data that measures what the ministers learnt by the end of the Forum and how equipped they felt to take action in the health sector; b. Provide the Harvard team with daily feedback from the ministers on the value of what they learnt on each day; c. Conduct interviews to gain closer insight into the scores provided by the ministers. The indicators for these assessments reflect the focus areas of the Forum. Three instruments were used to collect quantitative and qualitative information about participants perspectives on different parts of the program and whether they learnt anything new: A competency profile was designed to produce baseline scores for self-reported impact of the workshop. At the beginning of the Forum ministers were asked to rate the extent to which they felt equipped to carry out 0 competencies required to strengthen the public health sector. At the end of the Forum the same instrument was administered to capture final scores needed to assess what the ministers felt they had gained. These results were compared with their ratings at the start of the Forum. A daily assessment instrument was used to capture the extent to which the ministers felt they had improved their knowledge, confidence and skill in relation to the issues covered on that day. This

6 produced information that helped presenters take the temperature of the Forum on a daily basis, and indicates which sessions were most and least successful for the participants. An interview schedule was developed to guide the interviews conducted with the ministers at the end of the Forum. All nine participants completed the baseline competency assessment, but two did not compete the final assessment. The comparison of scores therefore reflects only the scores provided by the seven participants that completed both. The number of participants completing the daily feedback also varied somewhat (see Section and in Annexures, and ). Data analysis involved analysing the quantitative data recorded on the different instruments, and documenting the qualitative feedback received on different days. The quantitative data is presented in two ways: A competency profile was developed for individual participants and for the group as a whole, showing the changes in ratings that signify how well equipped the ministers felt to implement the 0 actions covered during the sessions. These findings are described in spider diagrams. A Net Confidence Rating (NCR) was computed to measure the spread between respondents who felt well-equipped or ill-equipped about a range of competencies, before and after the Forum. The net confidence rating illustrates the concentration of positive and negative responses for each action. Neutral responses are not taken into account since they do not add meaningful information to the analysis. A negative NCR indicates that more respondents felt ill-equipped than those who felt well-equipped. Given the small number of respondents (seven in this case), the net confidence increases should be regarded as indicative of the impact of the Forum.. Competency profile assessment Seven of the nine ministers completed a baseline competency barometer assessment on the first day of the Forum, and again at the close of the program. Two ministers had to leave before the follow up was completed and therefore they are not included in sections. and. of this report. However, their responses to proceedings on Day and Day are reflected in the reports in Annexures and. The assessment consisted of a set of ten actions related to the Forum content on the financing of health and social sector programs. Ministers used a point scale ( = not at all equipped ; = very well equipped ) to indicate the extent to which they felt equipped to carry out the following competencies: a. Develop a health budget decision-making framework in line with economic priorities b. Make the argument for prioritizing investment in health and the social sector as a pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen the health sector e. Structure a plan for sustainable financing for Universal Health Coverage f. Identify fiscal space in the health budget including revenue generating and cost saving opportunities g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health

7 h. Establish health budget effectiveness and efficiency performance measures and hold ministers and officials accountable i. Monitor progress and outcomes, and manage risk j. Leverage private sector investment to strengthen the public health sector A comparison of the scores provided at the baseline and follow-up assessment is provided below.. Changes in group feedback on self-reported competency levels The section compares the ratings on the set of ten indicators as provided at the start and close of the Forum. The aim is to identify shifts in reported levels of confidence over the course of the programme. There was a positive shift in levels of confidence from the baseline to the final assessment, with the overall average score increasing from.0 to.8 on the five point scale. Figure shows the average group scores for the baseline (blue) and follow up (orange) for the seven ministers who completed both assessments. Figure : Comparison of average group scores on the Competency Assessment Competency assessment - baseline and final comparison j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness & efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency & value for money in public health a. Develop health budget decision-making framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating & cost saving opportunities b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Baseline Follow-up Ministers reported an increase in levels of confidence on all ten of the actions listed. The largest gains in confidence were seen on the following four indicators: c. Identify opportunities for more effective and efficient health budget utilization (.7.) f. Identify fiscal space in health budget including revenue generating and cost saving opportunities (.9.0) h. Establish health budget effectiveness and efficiency performance measures and hold ministers and officials accountable (.7.7) i. Monitor progress and outcomes, and manage risk (.7.7) The action that showed the least improvement (.7 to ) also received the lowest rating at the follow up assessment, namely leveraging private sector investment to strengthen the public health sector. Figure shows the change between the average baseline and final scores per indicator.

8 Figure : Average group scores showing confidence ratings before and after the Forum By the end of the Forum, four actions received scores of (out of ) or higher, indicating high levels of confidence and showing that, as a group, ministers felt most equipped to: a. Develop health budget decision-making framework in line with economic priorities (.) b. Make argument for prioritizing investment in health and the social sector as pillar for national development (..) c. Identify opportunities for more effective and efficient health budget utilization (.) f. Identify fiscal space in health budget including revenue generating and cost saving opportunities (.0). As noted, by the follow up assessment, the group felt least equipped to leverage private sector investment to strengthen the public health sector.. Pre- and post-forum impact: Net confidence ratings Another way of viewing the impact of the Forum on the finance ministers, is to look at how the group s net confidence levels changed from feeling ill-equipped at the start, to feeling well-equipped by the end of the Forum. Although the analysis reflects a very small number of ministers (n=7), the trends evident in this analysis are interesting. Figures -7 illustrate these changes across the three key themes: Transformative leadership, health financing and the delivery approach. These results show that on eight out of ten competencies, the Forum succeeded in moving those ministers who felt illequipped to take these actions, to feeling neutral or well-equipped to do so. Transformative leadership: Although five of the seven ministers arrived at the Forum feeling well-equipped to advocate for investment in health, all seven ministers were very confident about this competence by the end (NCR = 00%). The largest confidence increase occurred in relation to structuring a public sector funding package for health, with net confidence levels 6

9 moving from -% at the start of the Forum to 7% by the end. The Forum also succeeded in doubling the number of ministers who felt well-equipped to develop a health budget decision-making framework. Figure : Transformative Leadership - net confidence ratings (n-7) Health financing: This was the area in which ministers made the largest gains, having felt least equipped for these competencies at the start of the Forum demonstrated by the negative net confidence levels shown in Figure 6. It is striking that the largest confidence increases occurred in relation to two competencies: first, identifying fiscal space in the health budget, where the confidence levels moved from negative (-9%) to positive (7%); second, the confidence to increase the effective and efficient utilization of the health budget moved from a negative level of -% to 86% by the end. The Forum made less of an impact on the ministers confidence to plan financing for Universal Health Coverage (moving from -9% to %) and to increase value for money in public health (moving from -% to 9%). A negative net confidence rating indicates that more respondents felt ill-equipped than well-equipped. 7

10 Figure 6: Health financing net confidence ratings (n=7) Using the delivery approach to achieve health priorities: The finance ministers recorded negative net confidence ratings in respect of holding the health minister and officials accountable for health sector performance, and for monitoring outcomes and managing risk (see Figure 7). The impact of the Forum is evident in being able to lift these net confidence ratings from -% to 7%, and from -% to 7% respectively. The lowest confidence levels were recorded for increasing private sector investment in health with net confidence ratings moving from 0% to %. This was also the only competence for which two ministers felt illequipped by the end of the Forum. Figure 7: Delivery approach net confidence ratings (n=7) 8

11 . Changes in individual feedback on self-reported competency levels The figures below compare the baseline (pre-forum) and final (post-forum) competency scores recorded by individual participants, and provide an indication of areas in which they grew in confidence, and areas that remain a challenge. Country There was an improvement on all but one of the indicators for the minister from Country. At the end of the Forum the minister mostly provided ratings of or, indicating high levels of confidence. The ratings remained unchanged for only one of the actions: at a consistent score of, the minister remained highly confident to make the argument for prioritizing investment in health and the social sector as critical to national development. Figure 8: Comparison of individual competency scores Country j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country a. Develop health budget decision-making framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Baseline Follow-up In several areas the minister showed notable improvements. Three actions received low confidence scores of (poorly equipped) at the baseline, but improved to (well equipped) at the follow up: c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable. The minister also felt better equipped in two other areas, moving from mid-range baseline scores of (somewhat equipped) to (very well equipped): a. Develop health budget decision-making framework in line with economic priorities 9

12 f. Identify fiscal space in health budget including revenue generating and cost saving opportunities. In an interview at the end of the Forum, the minister s description of the value of the Forum provides more insight into the learning he experienced: Country The issue of resource mobilization, fiscal space and then benchmarking, how do you prioritize, etc. So for many of those levels, I felt that I was really not very well equipped to deal with them. For example the issue of how do you mobilize financing, how do you get the private sector involved and during the sessions I could actually feel that my understanding of those issues has improved. So by the end of the session, my perception now is that I am better equipped to work with health sector issues in terms for example of helping rationalize the use of resources. How do you allocate resources to the health sector, how do you monitor the use of those resources, how do you work with the private sector. So I think on that front this forum was actually very helpful for me. This minister also showed an increase in reported confidence for all but one action by the end of the Forum. Top ratings were given to developing a health budget decision-making framework in line with economic priorities, and arguing for prioritizing investment in health and the social sector. The area that did not improve was structuring a plan for sustainable financing for Universal Health Coverage, which received a mid-range score of (somewhat equipped). Two other areas also received ratings of, suggesting some ambivalence in terms of confidence: structuring a public sector funding package to strengthen the health sector; and identifying, initiating and supporting strategic interventions for greater efficiency and value for money in public health. The lowest score at the follow up assessment ( out of ) was given to leveraging private sector investment. 0

13 Figure 9: Comparison of individual competency scores Country j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country a. Develop health budget decisionmaking framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities Baseline b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Follow-up At the end of the Forum, the minister commented that he found the sessions on leadership skills and the importance of primary health care to be some of the most useful aspects of the Forum: One is my leadership skills, training on persuasion, how you can be authentic - leadership, the qualities, and the values an effective leader can have. The second one is on primary healthcare services. I have a strong conviction on the significance of primary healthcare this training has given me more confidence, more inspiration. Also how low and middle income countries can deliver universal health coverage, how they can finance primary healthcare universally in their countries. So those were particularly useful. Country The scores provided by the minister from Country showed some improvement, but the pattern was less clear than in the case of other participants. The minister s ratings showed notable increases in reported confidence in three areas: b. Make the argument for prioritizing investment in health and the social sector as pillar for national development ( ) c. Identify opportunities for more effective and efficient health budget utilization ( ) i. Monitor progress and outcomes, and manage risk ( ). However, between the baseline and final assessments the minister recorded no change on six of the indicators. In one case structuring a public sector funding package to strengthen the health sector the rating was slightly lower than in the baseline assessment, declining from to.

14 Figure 0: Comparison of individual competency scores Country j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country a. Develop health budget decision-making framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities Baseline b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Follow up The minister departed before the end of the Forum, and interview comments were thus not available from him. Country The response from the minister from Country to the final competency assessment was unusual. On half of the indicators the ratings showed no change from those at the start of the forum. On the other half, the scores given at the final assessment were lower than those given in the baseline. These indicate that by the end of the Forum the minister was less confident in the following areas than at the start: a. Develop health budget decision-making framework in line with economic priorities ( ) g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health ( ) h. Establish health budget effectiveness and efficiency performance measures and hold ministers and officials accountable ( ) i. Monitor progress and outcomes, and manage risk ( ) j. Leverage private sector investment to strengthen the public health sector ( ). The decline in confidence ratings in respect of efficiency and effectiveness is notable. It is not clear what was driving these trends, but the minister s feedback during the Forum suggests that he was concerned about the applicability of the approaches covered in the workshop. He mentioned that different countries priorities are different and policies are different in different countries ; the modality of PPPs will differ from country to country ; and delivery modality was something very general not easy to generalize (different depending on nature of country). In his interview he also mentioned the difficulty he anticipated in introducing the health financing measures discussed at the Forum, because at present access to health services and to education is free of charge.

15 Figure : Comparison of individual competency scores Country j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country a. Develop health budget decision-making framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Baseline Follow up Country The minister from Country reported an improvement in confidence in five of the competencies listed, and by the end of the Forum indicated that he felt very well equipped to carry out eight of the ten actions. As is shown in the list below, the ratings show increased confidence in five of the areas discussed, and indicate that the minister retained his high confidence levels shown at the start of the Forum for three others. Overall, by the final assessment the minister felt very confident about eight of the ten actions, rating them out of. The minister gave mid-range scores ( somewhat equipped) to two of the actions. These were structuring a plan for sustainable financing for Universal Health Coverage; and leveraging private sector investment to strengthen the public health sector.

16 Figure : Comparison of individual competency scores Country j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk Country a. Develop health budget decision-making framework in line with economic priorities b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable d. Structure a public sector funding package to strengthen health sector g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health f. Identify fiscal space in health budget including revenue generating and cost saving opportunities e. Structure a plan for sustainable financing for Universal Health Coverage Baseline Follow up In reflecting on his experience of the Forum, he described how he felt better equipped for his role in government: Country 6 I was fortifying in some areas I knew because I am an economist by training, so some of this stuff is not relatively new to me, but fortifying and brought up to date with what is happening in the rest of the world and in the literature per se. And I learnt in terms of new perspectives that had been given on priority setting, on leadership, sustainability, tracking and trajectories these were all new approaches to the teaching and the delivery of the subject. I am fascinated enough that I have started reading some of the voluminous literature that has been given to us. The minister from Country 6 reported increased confidence in all areas. He provided particularly low scores in the baseline (seven indicators were rated at, indicating that he felt poorly equipped in these respects), but showed improvement on all of competencies in the final assessment. At the end of the Forum, the minister was confident to carry out seven of the ten actions (rating them at or ). Three areas improved from poorly equipped to somewhat equipped, indicating continued ambivalence: g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health ( ) h. Establish health budget effectiveness and efficiency performance measures and hold ministers and officials accountable ( ) i. Monitor progress and outcomes, and manage risk ( )

17 Figure : Comparison of individual competency scores Country 6 j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country 6 a. Develop health budget decisionmaking framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities Baseline b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Follow up In his interview the minister commented that the components on leadership were very useful to his role as Minister of Finance, and that it was very useful to hear about some of the modern methods of planning to set priorities to make investments in health and to get the feedback and then come back and make the adjustments. However, his mid-level ratings of on three of the operational capabilities suggest that further support may be helpful to him. Country 7 The minister from Country 7 also reported increased confidence across the board. This minister had given low scores (one of and six of ) in the baseline assessment, but by the follow up most of the actions were scored, with two receiving a mid-range score of. The two items receiving the lowest confidence ratings () were identifying, initiating and supporting strategic interventions for greater efficiency and value for money in public health ; and leveraging private sector investment to strengthen the public health sector.

18 Figure : Comparison of individual competency scores Country 7 j. Leverage private sector investment to strengthen public health sector i. Monitor progress and outcomes, and manage risk h. Establish health budget effectiveness and efficiency performance measures; hold ministers and officials accountable g. Identify, initiate and support strategic interventions for greater efficiency and value for money in public health Country 7 a. Develop health budget decisionmaking framework in line with economic priorities f. Identify fiscal space in health budget including revenue generating and cost saving opportunities b. Make argument for prioritizing investment in health and the social sector as pillar for national development c. Identify opportunities for more effective and efficient health budget utilization d. Structure a public sector funding package to strengthen health sector e. Structure a plan for sustainable financing for Universal Health Coverage Baseline Follow up During her interview the minister described the value of the Forum as follows: I am better equipped in terms of I think I can easily champion, I understand my colleague from the health sector and also discuss with the Government the tools that we got to see the value addition, how the primary health care system is fundamental, how it can reach a large number of the population, how also we can use a system of planning of monitoring and evaluation, which is accountability, which is good governance. I think that is why I say equipped it has been done in a systematic manner. I think that is the value addition that I saw in the seminar. What is likely to change? Six of the finance ministers were interviewed at the end of the Forum to gain more insight into what they had found most helpful, what they planned to do next, and how this might impact on the heath sector in their countries. The ministers interviewed were from the Bahamas, Bhutan, Ethiopia, Guinea- Bissau, Guyana and Burkina Faso.. Impact on ministers leadership role In reflecting on which parts of the Forum were most useful, four of the six ministers mentioned the Forum s impact on their leadership capability particularly in respect of health, but also applying these approaches more widely in their work. Two comments are instructive: the first refers to how personal traits can produce a stronger sense of agency; the second mentions the importance of a leadership role in all areas of the ministers work: Very useful were the elements on leadership, and what I got out of that was being able to use my own personal attributes and being able to bring those to bear on what we need to do as ministers of finance and particularly when we start to talk about allocating resources for health. (Country 6) 6

19 the leadership role that we can play in the health sector can also be played in different areas of our work. That is really important: how we should behave, how we can create trust, how we can have a vision be a visionary etc. (Country 7) Some ministers specifically mentioned the value of building their understanding of approaches such as prioritizing, planning, persuasion, budget allocation, tracking, assessing the impact of interventions, and sustainability, and one commented that these skills will make him more effective in terms of delivery public services (Country ): it brings more of a scientific approach in terms of setting the priorities, being able to measure your results, getting feedback and making changes. (Country 6) I think the whole issue was on leadership but if you get into the detail it is about setting up priorities. And because the resources are limited you cannot afford to waste them. (Country ) These perspectives are reflected in the ministers confidence ratings recorded during the Forum. Figure shows that the group as a whole recorded 00% confidence levels in respect of setting legacy goals, and maintained high confidence levels for advocating for prioritizing government investment in health (net confidence rating of 7%). However, confidence levels were lower for getting support for these goals (net confidence rating of 6%). Figure Transformational leadership: Net confidence ratings (NCR) Set priorities for my legacy Get support for my goals Track my personal performance against my legacy goals NCR 00% 6% 7%. Health as a priority for national development The Forum s impact on the ministers understanding of health in the context of national development, emerges clearly from the interviews. It is also interesting to see how it changed their perceptions of health as a significant area of investment: We [now] know that the health sector is not only for spending. It s for improving the quality of life of the population and it is also improving the human capital and, at the end, it is also improving their contribution to development. So that is really important because sometimes, we do not take the time to make the analysis. and how the budget can be allocated to make These diagrams (and those below) record the ministers ratings provided at the end of each day. Two of the ministers did not take part in the sessions on Day, which is why a lower number of ratings are described on some bars. 7

20 sure that we have value for money and also value for many. That is a new concept that I think is very good for the poor people, for those who are lagging behind. (Country 7) I learnt a lot about health. Actually I am not a health specialist. This gives you the opportunity to broaden your view about the health sector. And at the beginning of the session, I pointed at my legacy as Minister of Finance that I would like to be remembered as one who introduced VAT in my country. I didn t change my view, but what has changed now is the perception that I now have on how to work with the health people, particularly with the Ministry of Health. So what changed actually is the perception, and that is why I said at the end that the first thing I will do next week when I arrive home is to have lunch with the Minister of Health and start this conversation about how we will work together. (Country ) A number of the ministers mentioned that they are now convinced about the importance of Primary Health Care as a priority for their countries. In some cases the Forum convinced the ministers to champion Primary Health Care as a priority strategy and helped equip them to provide meaningful support to these efforts; in another case it reinforced what is already taking place in their country: [I] have accepted that a big part of improving universal health coverage is improving access to primary care, good access to primary care so that people are satisfied and feel confident going to the primary health care clinics. That is something that we are pursuing and this reinforces the correctness of that approach. (Country 6) I have a strong conviction on the significance of primary health care this training has given me more confidence, more inspiration. Lessons also from other countries that have done even better and the possibility of financing primary health care, the issue of universal health coverage. (Country ) My perception now is that I am better equipped to work with health sector issues in terms for example of helping rationalize the use of resources. How do you allocate resources to the health sector, how do you monitor the use of those resources, how do you work with the private sector. So I think on that front this forum was actually very helpful for me. (Country ) I think I can easily champion, I understand my colleague from the health sector and also discuss with the Government the tools that we got to see the value addition, how the primary health care system is fundamental, how it can reach a large number of the population (Country 7) These views are reflected in the net confidence ratings shown in Figure 6. The group produced high net confidence ratings for advocating for investment in public health, and supporting the health minister s priorities (NCR of 89% and 7% respectively), and six out of nine ministers felt well equipped to do so. However, while most of the ministers felt equipped to drive choices to achieve greater value for money in public health delivery (NCR 6%), fewer felt well equipped to achieve this in practice (NCR 8%). 8

21 Figure 6: Support for health as a priority: Net confidence ratings (NCR) Argue for investment in health Support the health minister to achieve better results with available resources Work with the health minister to increase health performance Drive choices to achieve greater value for money in public health delivery Support strategic interventions for greater efficiency and value for money in public health NCR 89% 7% 6% 6% 8%. Impact on the finance minister s job Will these finance ministers transform their leadership? And how might they do so in relation to the health sector? Two ministers said they need to get more involved in the detail of budgeting for health. Another intended restructuring his management team and focusing on goal setting. A fourth mentioned that she would apply her new-found skills in getting her team to see health in a new light and produce a very focused mid-term plan. I think sometimes we leave the fine details to the officials. I think what we need to do is myself and the health minister and the budget officials and his finance officials need to sit down and go through in fine detail what it is they need, what they are trying to achieve, how they are going to measure it and make sure we prioritize. I think sometimes we fall into the trap of just adding a percentage into the budget, but what this assures me is we really need to go and see what it is we are trying to achieve and look at specific outcomes and how we are going to do that and redirect more money to it, and put in performance measurement. (Country 6) I already have a management team in place, so I will be doing a bit of restructuring and goal setting I am going to use [someone in my team] as my cheer leader in terms of championing what exactly we have been trying to put in place for the past months, which is when I became a Minister. (Country ) [In] the social sectors, including health, the perception was that they take money but they do not pay back. I now have the prism of reading the health sector, that is number one. And number two, I will take steps with my team, with the technical people, since now we are preparing our mid-term plan. those tips that I got, I will brief my colleagues and involve them in seeing things differently and having a really focused plan, targeting the people in need. (Country 7) The ministers recorded high confidence levels to apply the delivery approach, with the exception of three areas in which confidence levels were notably lower (see Figure 7): using performance data to drive health budget decision-making; assess critical success factors in public-private partnerships; and 9

22 manage risk. It is not clear what was driving these low confidence ratings, but it may be that the presentations on these topics were not as effective as the others. Figure 7: Organizing to deliver: Net confidence ratings (NCR) Organize better implementation of policy priorities. Establish monitoring routines and performance indicators Hold officials accountable against efficiency and outcome targets Use performance data to drive health budget decisionmaking Assess the critical success factors and risks in publicprivate partnerships for health Manage risk NCR 00% 86% 86% % % % A comment by one of the ministers suggests that despite some ministers recording mid- to low confidence levels for using performance data to drive health budget decision-making, the Forum succeeded in conveying the importance of monitoring performance and outcomes: In terms of monitoring, the Ministry of Finance and in my case, I would say, was not actually very interested in looking closely at what is going on in the health sector. Why? Because usually you just give money and hope that the money is well spent, thinking that this is out of our mandate. So now I have a different perception I will give more money, but at the same time I am interested in knowing what happens to the money that I give to the sector. (Country ). Challenges Three of the six ministers interviewed cited a lack of financial resources and competing priorities as the major challenges they will face in increasing their health budgets. At the same time they indicated that the Forum had provided numerous ways in which they could tackle these problems by reallocating budgets, creating fiscal space, pooling funds, achieving value for money, and introducing taxes on tobacco and alcohol to mobilise more resources. I think the critical challenge is mobilizing sustainable source[s] of finance for healthcare. We will increase resource mobilization and allocate more for health, and improve the use of the resources already at hand. We have seen many mechanisms by which we could do more with the resources that we have, such as improving efficiencies and the effectiveness of our resources. (Country ) Other challenges were also cited. One minister mentioned that in his country our people are used to getting everything free the entire health system is free in our country; education is free until college. His concern was: 0

23 If you set priorities, suddenly there would be a change in the health care system and there will be a lot of lashing from the people. we may have to withdraw certain facilities and then we may prioritize others. But when the society is so used to getting everything for free, the moment you set priorities it means there is going to be distortion in the service to the public.... This is going to be a challenge. We need to have a lot of awareness programmes telling people what the priorities of the health system in the country are based on: certain facts and figures - for instance infant mortality, non-communicable diseases... so that people are receptive of the challenges and priorities that you set, so that the policy drive could be implemented successfully. (Country ) Two of the ministers mentioned geographic factors as being the major hindrance to improving their health systems, given the massive costs associated with reaching their far-flung populations: We have about 0 major islands and so we have to duplicate things for all these islands. We have begun to use the concept of telemedicine so that we connect them electronically, but that is the greatest challenge our geography. the second challenge is the availability of trained personnel to man all these bases because Work with the health minister to identify fiscal space in the health budget NCR 88% of our geography (Country 6) transportation and communication and personnel. [Ours] is a reasonably large country with a very small population. The bulk of the population lives in the coastline, which lies below sea level and just about one third of the population is scattered all over the place. So there are huge challenges in terms of delivering quality healthcare from a geographic stand point. (Country ) This minister mentioned two other challenges: first, there is little research available on tropical diseases that occur in his country; second, the country has attempted to use a hub and spoke model for health service delivery, but with little success: The people aren t convinced enough to go to the spokes because we are not able to equip these spokes enough, so they end up right back to the centre. They are abandoned. you have got a lot of structures built around the place that are decaying because you don t have a nurse, you don t have a medic or the doctors, you don t have the drugs, you don t have the delivery of these services and then of course like what he said, some of these areas are so far flung you have to fly out. we have got to do what we do right, better, and do what we are doing wrong, right.. Collaboration between finance and health ministers Most of the finance ministers suggested that they would benefit from closer collaboration with their health minister, and felt that this would be possible: Definitely, to understand more effective interventions that improve health outcomes and efficiencies in terms of resource use. The Minister of Health and I need to have a shared vision given that the National Agenda will outline the health sector objectives. (Country ) Since I am the Minister for Development, we have projects to sign together etc. We work very closely and also for the allocation of resources. But now the relationship should be deeper in terms of working together, understanding more and also giving advice you know your plan