Ministerial Leadership in Health Program Ministerial Forum for Finance Ministers

Transcription

1 Ministerial Leadership in Health Program Ministerial Forum for Finance Ministers Harvard University April 19, 01 In association with the Children s Investment Fund Foundation (UK) EVALUATION REPORT Analysis and Compilation by Helene Perold and Aislinn Delany for Helene Perold & Associates i

2 Table of Contents 1 Introduction... Overview of evaluation findings... Evaluation methodology... Competency barometer assessment....1 Changes in group feedback on self-reported competency levels.... Changes in individual feedback on self-reported competency levels... 7 Country (1)... 7 Country ()... 8 Country... Error! Bookmark not defined. Country 8... Error! Bookmark not defined. Country... Error! Bookmark not defined. Country 1... Error! Bookmark not defined. Country 7... Error! Bookmark not defined. Country 9... Error! Bookmark not defined. Country 6... Error! Bookmark not defined. Country (a)... 1 Country (b) What is likely to change? Impact on the finance minister s job Challenges likely to be faced Prospects for collaboration between finance and health ministries Other suggestions... 1 Annexure 1 Ministerial Forum for Finance Ministers Program... Annexure Day feedback report... Annexure Day feedback report

3 1 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 corner stone of economic development and sustainable growth, and to explore analytical tools and practical ideas for improving standards of public health care and health outcomes by achieving greater efficiency in health resource utilization. The 01 Forum convened 1 participants from 11 countries: Bangladesh, Burkina Faso, Cape Verde, The Gambia, Haiti, Honduras, Cote d Ivoire, Lesotho, Liberia, Swaziland and Uganda. 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. This report outlines the learning recorded by each of the participants over the course of the four days and documents how they rated changes in their knowledge and their competence to support health sector strengthening. Overview of evaluation findings The finance ministers participating in this Forum differed in their levels of experience and in their engagement with health issues. Some were relatively new in their posts, others more experienced, and in one case a participant had engaged extensively with the health ministry in his country whilst dealing with the Ebola crisis. No matter their level of experience, the group started the Forum with mid-level confidence and skill ratings across a set of ten competencies. The competency assessment covered three themes: transformational leadership, health financing, and getting better value for public expenditure in health. By the end of the Forum, the group increased their knowledge and confidence across nine out of the ten indicators, with the average group score moving up from. (out of ) to. Significantly, at the close of the Forum the group felt most equipped to undertake three actions, all of which are associated with health financing: (a) identify fiscal space in the health budget including revenue generating and cost saving opportunities; (b) develop strategies for improved efficiency and value for money in health; and (c) negotiate with private sector investment partners to strengthen the health sector. Closely associated with these actions were two others in which the group demonstrated large improvements in knowledge and confidence: Develop a health budget decision-making framework, and structure a public sector funding package to strengthen the health sector. These results show that the Forum succeeded in convincing the finance ministers that investment in public health strengthening is in the interest of national economic development. It also gave them the knowledge and skill to design and implement the measures required to increase fiscal space in the health budget, and improve the efficiency and effectiveness of health expenditure. Confidence levels at the end of the Forum were high for five participants whose scores indicated that they felt between 81% and 100% confident that they are very well equipped to implement the approaches discussed. Five others showed confidence levels of between 61% and 80%, while one participant showed a confidence level of 8%.

4 The areas in which the participants scored themselves lowest are risk management, strengthening public service delivery, and using the health budget more effectively and efficiently. The latter is somewhat surprising in view of the high confidence rating given above to improving efficiency and value for money in health. Interviews and written comments show that participants found value in the sessions on transformational leadership, health financing, managing resource allocation in government, and how to avoid wastage in public spending through measures that increase efficiency, transparency and accountability. As might be expected, resource mobilization was cited as a challenge, but it seems that the Forum was successful in presenting approaches that would enable the ministers to make better use of the resources at their disposal (by reprioritizing areas of expenditure, working more efficiently, etc) and generate additional financial resources. The finance ministers were positive about the prospects for collaborating closely with their counterparts in health, and cited practical measures they intended taking to implement some of the ideas and approaches gained from the Forum. These include developing a working relationship and a common understanding between health and finance of how best to prioritize the health budget; how to generate revenue and save costs; how to achieve universal health coverage; presenting proposals for taxing tobacco and alcohol; and meeting regularly to monitor progress and track outcomes. Despite the Forum being an intensive four-day experience, the interviews and comments on the final competency assessment indicate that participants found it a rewarding and valuable use of their time. Evaluation methodology 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 data that measures what the Ministers feel they have learnt in the course of the forum; b. Provide the Harvard team with daily feedback from the Ministers on the value of what they learnt on the day; c. Gain closer insight into the scores provided by the Ministers. Two types of self-assessment instruments were used to collect quantitative information about participants perspectives on the value of the different parts of the program and whether they have learnt anything new: A competency barometer 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 10 competencies required to strengthen the public health sector. Ministers were also asked to write a sentence explaining their scores, and this provided some insight into the ratings given. At the end of the forum the same instrument was administered to capture final scores needed to assess what the ministers had learnt over the three days.

5 A daily assessment instrument was used to capture the extent to which the Ministers felt they had improved their knowledge and skill in relation to the issues covered. This produced information that helped presenters take the temperature of the forum on a daily basis. The indicators for this assessment were drawn from the content planned for each day. Thirteen participants from 11 countries 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 11 participants that completed both. The number of participants completing the daily feedback also varied slightly (these details are specified in Annexures and ). Competency barometer assessment Eleven of the 1 participants completed the Competency Barometer assessment on the first day of the program, and again at the close of the program. The Competency Barometer consisted of the participants rating the extent to which they felt equipped to carry out 10 competencies related to the role of Finance Minister in supporting the financing of public health. A five point scale was used, in which a score of 1 indicated not at all equipped and a score of indicated very well equipped. Participants rated themselves on the following competency indicators: 1. Develop a health budget decision-making framework in line with economic priorities. Identify opportunities for more effective and efficient health budget utilization. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national public health as a pillar for national development. Establish health budget performance measures and hold ministers accountable 6. Develop strategies for improved efficiency and value for money in health 7. Structure a public sector funding package to strengthen the health sector 8. Identify fiscal space in the health budget including revenue generating and cost saving opportunities 9. Negotiate with private sector investment partners to strengthen the health sector 10. Identify risks to effective implementation and manage risk mitigation strategies A comparison of the scores given at the beginning (baseline) and end of the Forum (follow-up assessment) is provided below. The aim of the comparison is to show shifts over the course of the programme..1 Changes in group feedback on self-reported competency levels In general there was a positive shift in the average scores provided by the participants who completed both the baseline and final competency barometer, with the average overall score increasing from. to (out of ). All but one of the individual indicators showed an improvement. Figure 1 compares the average group scores for the baseline (in blue) and follow up assessment (in orange) for the 11 participants who completed both assessments.

6 Figure 1: Comparison of average group scores on the Competency Assessment Competency assessment - baseline and final comparison 10. Identify risks to effective implementation and manage risk mitigation strategies 9. Negotiate with private sector investment partners to strengthen the health sector 8. Identify fiscal space in the health budget including revenue generating and cost saving opportunities 1. Develop a health budget decisionmaking framework in line with economic priorities,0,0,0,0 1,0. Identify opportunities for more effective and efficient health budget utilization. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national public health as a pillar for national development 7. Structure a public sector funding. Establish health budget performance package to strengthen the health measures and hold ministers sector accountable 6. Develop strategies for improved efficiency and value for money in health Baseline Follow up The following table shows the change between the baseline and final scores per indicator. The group showed improvement in nine out of ten indicators and a slight decrease in respect of indicator. Competency indicator Baseline group average Final group average 1 Develop a health budget decision-making framework in line with economic priorities..0 Identify opportunities for more effective and efficient health budget utilization..8 Lead efforts to strengthen public service delivery.8.7 Make the argument for prioritizing investment in national public health as a pillar for national development Establish health budget performance measures and hold ministers accountable 6 Develop strategies for improved efficiency and value for money in health 7 Structure a public sector funding package to strengthen the health sector 8 Identify fiscal space in the health budget including revenue generating and cost saving opportunities 9 Negotiate with private sector investment partners to strengthen the health sector 10 Identify risks to effective implementation and manage risk mitigation strategies These results indicate that by the end of the Forum, participants felt most confident about identifying fiscal space in the health budget and improving efficiency to get more value for money in health.

7 The biggest improvements in knowledge and confidence were reported for the following actions: Develop a health budget decision-making framework in line with economic priorities Structure a public sector funding package to strengthen the health sector Identify fiscal space in the health budget including revenue generating and cost saving opportunities All three indicators are related to aspects of health financing and the scores show that in these areas participants made the largest gains in knowledge and confidence. By the end of the Forum, the group felt most equipped to: Develop strategies for improved efficiency and value for money in health (a rating of. out of ) Identify fiscal space in the health budget including revenue generating and cost saving opportunities (rated. out of ) Negotiate with private sector investment partners to strengthen the health sector (rated.1 out of ). As a group, participants felt least equipped to: Identify risks to effective implementation and manage risk mitigation strategies (rated. out of ) Lead efforts to strengthen public service delivery (rated.7 out of ) Identify opportunities for more effective and efficient health budget utilization (rated.8 out of ). The group score for leading efforts to strengthen public service delivery is interesting. In the baseline assessment this indicator was rated.8, which was the highest rating given at that time. In the final assessment the indicator drew a rating of.7, which was one of the lowest ratings provided by the group. This was one of two indicators associated with the transformational leadership component of the program. The other was making the argument for prioritizing investment in national public health as a pillar for national development. In this case the group rating increased considerably from. to. Another perspective looks how, at the end of the Forum, participants scored their overall improved confidence levels. The table below calculates each participant s aggregate final score as a percentage of the highest rating ( feeling very well equipped to undertake the ten actions) and shows the results against percentiles for each category. Country Not at all equipped 0-0% confidence level Poorly equipped 1-0% confidence level Somewhat equipped 1-60% confidence level Country (a) 8% Well equipped 61-80% confidence level Very well equipped % confidence level Country (b) 86% Country 80% Country 8 90% Country 90% Country 1 7% Country 7 6% 6

8 Country Not at all equipped 0-0% confidence level Poorly equipped 1-0% confidence level Somewhat equipped 1-60% confidence level Well equipped 61-80% confidence level Country 9 7% Country 6 7% Very well equipped % confidence level Country (a) 8% Country (b) 88% This view shows that by the end of the Forum five out of eleven participants felt very well equipped to carry out the actions listed in the competency barometer; five out of eleven felt well equipped; and one participant felt somewhat equipped to carry out these actions. These results indicate that the Forum made a strong impact on almost all participants.. Changes in individual feedback on self-reported competency levels The following section provides a review of the feedback given at an individual level. The figures below present a comparison of baseline and final competency scores for individual participants, providing an indication of competencies in which they grew in confidence, and areas of competency that remain a challenge. Please note that the participants from Countries 10 ad 11 both had to leave the Forum before the final competency assessment was undertaken and their results are thus not included in this report. Country (participant a) On seven of the 10 competency indicators the scores given by the first participant from Country remained the same over the course of the program (items 1,,,, 6, 9 and 10). Figure : Comparison of individual competency scores Country (a) Competency assessment - Country (a) 1. Develop a health budget decision-making framework. Identify opportunities for more effective & efficient. Lead efforts to strengthen public service delivery. Argue for prioritizing investment in national public. Establish health budget performance measures & hold 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package 8. Identify fiscal space in health budget 9. Negotiate with private sector investment partners 10. Identify risks to effective implementation & manage Baseline Follow up 7

9 Of the other indicators, the scores given on two health-financing indicators were lower in the final assessment: Establish health budget performance measures and hold ministers accountable ( ) 7 Structure a public sector funding package to strengthen the health sector ( ) However, the indicator relating to identifying fiscal space in the health budget including revenue generating and cost saving opportunities (item 8) showed a notable increase in the final assessment, shifting from a low initial score of 1 to a more confident score of. Country (participant b) Although some of the scores provided by the second participant from Country were lower on the follow up assessment than on the baseline, the scores given in the follow up assessment were all s or s, indicating a high level of confidence in his ability to support the health sector. Figure : Comparison of individual competency scores Country (b) Competency assessment - Country (b) 1. Develop a health budget decision-making framework in line. Identify opportunities for more effective and efficient health. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national. Establish health budget performance measures and hold 6. Develop strategies for improved efficiency and value for 7. Structure a public sector funding package to strengthen the 8. Identify fiscal space in the health budget including revenue 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and manage risk 0 1 Baseline Follow up There was a notable improvement on item, or identifying opportunities for more effective and efficient health budget utilization. The item received a score of in the baseline assessment, but this increased to by the follow up. A second value for money indicator, identifying risks to effective implementation and managing risk mitigation strategies (item 10) also showed an increase, from in the baseline assessment to in the follow up. A similar increase was found with regards to developing strategies for improved efficiency and value for money (item 6: ), and negotiating with private sector investment partners (item 9: ) Three items that had received the highest possible score in the baseline (two relating to transformational leadership items and, and one relating to achieving value for money, item ) decreased slightly in the follow up assessment. However, they were all given a high score of in the follow up, indicating that the participant remained confident in these areas. Three indicators remained the same (items 1, 7 and 8), all with high scores of or. 8

10 Country The scores provided by the participant from Country in the follow up all fell within the to range, with several showing improvements from the baseline assessment. Figure : Comparison of individual competency scores Country Competency assessment - Country 1. Develop a health budget decision-making framework. Identify opportunities for more effective and efficient. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in. Establish health budget performance measures and 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package to 8. Identify fiscal space in the health budget including 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and 0 1 Baseline Follow up Increases of two points were found for the following four health-financing and risk management items: 1 Develop a health budget decision-making framework in line with economic priorities ( ) 7 Structure a public sector funding package to strengthen the health sector ( ) 8 Identify fiscal space in the health budget including revenue generating and cost saving opportunities ( ) 10 Identify risks to effective implementation and manage risk mitigation strategies ( ) Other leadership and value for money indicators also showed an increase, as follows: Make the argument for prioritizing investment in national public health as a pillar for national development ( ) Establish health budget performance measures and hold ministers accountable ( ) Only one indicator, relating to negotiating with private sector investment partners, remained the same (item 9 with a score of ). Two other value for money indicators showed a slight decrease, but despite this, the final scores of remained high: Identify opportunities for more effective and efficient health budget utilization ( ) 6 Develop strategies for improved efficiency and value for money in health ( ) Leading efforts to strengthen public service delivery was given the highest possible score by the participant from Country in the baseline, but was not scored again in the follow up. 9

11 Country 8 The participant from Country 8 tended to allocate high ratings to the indicators in both the baseline and in the follow up assessment. Only one indicator was scored below in the baseline - item 6 on developing strategies for improved efficiency and value for money was rated at the baseline, but this improved to a score of in the follow up. Figure : Comparison of individual competency scores Country 8 Competency assessment - Country 8 1. Develop a health budget decision-making framework in line. Identify opportunities for more effective and efficient health. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national. Establish health budget performance measures and hold 6. Develop strategies for improved efficiency and value for 7. Structure a public sector funding package to strengthen the 8. Identify fiscal space in the health budget including revenue 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and manage risk 0 1 Baseline Follow up Three other indicators also showed improvements: 1 Develop a health budget decision-making framework in line with economic priorities ( ) Identify opportunities for more effective and efficient health budget utilization ( ) 7 Structure a public sector funding package to strengthen the health sector ( ) The scores given to the other indicators did not change, but remained at a relatively high level of confidence and knowledge (reflected by the scores of and ). No decreases were noted for this participant. Country The participant from Country indicated a high level of confidence on the follow up assessment, giving five of the indicators the highest possible score, and giving the others a score of. 10

12 Figure 6: Comparison of individual competency scores Country Competency assessment - Country 1. Develop a health budget decision-making framework in line. Identify opportunities for more effective and efficient health. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national. Establish health budget performance measures and hold 6. Develop strategies for improved efficiency and value for 7. Structure a public sector funding package to strengthen the 8. Identify fiscal space in the health budget including revenue 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and manage risk 0 1 Baseline Follow up The most notable increase was on the indicator on establishing health performance measures and holding ministers accountable (item ), which increased from at the baseline assessment to in the follow up assessment. Other increases were shown on the following indicators: Identify opportunities for more effective and efficient health budget utilization ( ) Make the argument for prioritizing investment in national public health as a pillar for national development ( ) Slight decreases were noted on two indicators (items and 6), but since the scores decreased from to, these are not areas for concern because at a rating of the final scores remained relatively high. The other five indicators (items 1 and 7-10) remained the same, with high scores of and. Country 1 The scores given by the participant from Country 1 remained remarkably consistent across the baseline and follow up indicators, with only two of the 10 indicators changing over time. All of the scores remained within the narrow band of to, indicating that the participant feels relatively confident but that there is room for further support. 11

13 Figure 7: Comparison of individual competency scores Country 1 Competency assessment - Country 1 1. Develop a health budget decision-making framework in line. Identify opportunities for more effective and efficient health. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in national. Establish health budget performance measures and hold 6. Develop strategies for improved efficiency and value for 7. Structure a public sector funding package to strengthen the 8. Identify fiscal space in the health budget including revenue 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and manage risk 0 1 Baseline Follow While the participant grew in confidence in developing a health budget decision-making framework in line with economic priorities (item 1, ), a slight decrease was seen on identifying opportunities for more effective and efficient health budget utilization (item, ). Scores for the other indicators remained the same. The indicators that received mid-level scores of on the follow up assessment and which may indicate areas requiring further support are: Identify opportunities for more effective and efficient health budget utilization ( ) Lead efforts to strengthen public service delivery () 6 Develop strategies for improved efficiency and value for money in health () 10 Identify risks to effective implementation and manage risk mitigation strategies () Country 7 There was a lot of variability in the scores provided by the participant from Country 7, but overall the scores given in the follow up assessment showed an improvement from those given in the baseline. 1

14 Figure 8: Comparison of individual competency scores Country 7 Competency assessment - Country 7 1. Develop a health budget decision-making framework in line. Identify opportunities for more effective and efficient health. Lead efforts to strengthen public service delivery 1. Make the argument for prioritizing investment in national. Establish health budget performance measures and hold 6. Develop strategies for improved efficiency and value for 7. Structure a public sector funding package to strengthen the 1 8. Identify fiscal space in the health budget including revenue 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and manage risk Baseline Follow up Two indicators remained the same (items and ), while increases were noted on six indicators as follows: 1 Develop a health budget decision-making framework in line with economic priorities (1 ) Lead efforts to strengthen public service delivery ( ) 6 Develop strategies for improved efficiency and value for money in health ( ) 8 Identify fiscal space in the health budget including revenue generating and cost saving opportunities ( ) 9 Negotiate with private sector investment partners to strengthen the health sector ( ) 10 Identify risks to effective implementation and manage risk mitigation strategies (1 ) Although they showed an increase by the follow up assessment, items 1 and 10 only received scores of in the follow up assessment, indicating that these remain areas of concern for the participant from Country 7. Developing a health budget decision-making framework and risk management are both essential in strengthening the health sector, suggesting that this participant would benefit from additional support. No score was given in the follow up assessment for structuring a public sector funding package to strengthen the health sector, but the baseline score of 1 suggests this is a further area for additional support. Country 9 In both the baseline and the follow up assessment, the participant from Country 9 provided mid-range scores of and. 1

15 Figure 9: Comparison of individual competency scores Country 9 Competency assessment - Country 9 1. Develop a health budget decision-making framework. Identify opportunities for more effective and efficient. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in. Establish health budget performance measures and 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package to 8. Identify fiscal space in the health budget including 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and 0 1 Baseline Follow up The scores given to half of the indicators showed no change over the program period, with four of the five indicators remaining at a high score of. Three indicators, all associated with measures to increase efficiencies in the health system, showed a slight decrease at the follow up assessment from a score of to : Identify opportunities for more effective and efficient health budget utilization ( ) Establish health budget performance measures and hold ministers accountable ( ) 6 Develop strategies for improved efficiency and value for money in health ( ) Encouragingly, two other health-financing indicators showed an improvement at the follow up assessment, increasing from to : 7 Structure a public sector funding package to strengthen the health sector ( ) 8 Identify fiscal space in the health budget including revenue generating and cost saving opportunities ( ) Country 6 The scores given by the participant from Country 6 showed a great deal of variability, with a clear increase in confidence by the follow up assessment. 1

16 Figure 10: Comparison of individual competency scores Country 6 Competency assessment - Country 6 1. Develop a health budget decision-making framework. Identify opportunities for more effective and efficient. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in. Establish health budget performance measures and 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package to 8. Identify fiscal space in the health budget including 1 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and 0 1 Baseline Follow up Seven of the 10 indicators showed a positive improvement over the course of the program. Two of the largest increases were found on indicators associated with increasing efficiencies in the health system: Identify opportunities for more effective and efficient health budget utilization (1 ) 6 Develop strategies for improved efficiency and value for money in health ( ) Other indicators, including the health-financing items, also showed improvements: 1 Develop a health budget decision-making framework in line with economic priorities ( ) Make the argument for prioritizing investment in national public health as a pillar for national development ( ) Establish health budget performance measures and hold ministers accountable ( ) 7 Structure a public sector funding package to strengthen the health sector ( ) 9 Negotiate with private sector investment partners to strengthen the health sector ( ) The one remaining area of concern is leading efforts to strengthen public service delivery. The scores for this indicator decreased from to, reflecting low levels of confidence in carrying out this leadership function. Country (a) The scores given by participant A from Country ranged from to on both the baseline and follow up assessments, indicating a relatively high degree of confidence and knowledge. 1

17 Figure 11: Comparison of individual competency scores Country (a) Competency assessment - Country (a) 1. Develop a health budget decision-making framework. Identify opportunities for more effective and efficient. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in. Establish health budget performance measures and 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package to 8. Identify fiscal space in the health budget including 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and 0 1 Baseline Follow up Three items relating to leadership and value for money were given top scores of at the follow up assessment, as follows: Lead efforts to strengthen public service delivery () 6 Develop strategies for improved efficiency and value for money in health ( ) 8 Identify fiscal space in the health budget including revenue generating and cost saving opportunities () Four indicators that improved at the follow-up assessment were related to transformational leadership and getting value for money: Make the argument for prioritizing investment in national public health as a pillar for national development ( ) 6 Develop strategies for improved efficiency and value for money in health ( ) 9 Negotiate with private sector investment partners to strengthen the health sector ( ) 10 Identify risks to effective implementation and manage risk mitigation strategies ( ) All scores given at the follow up assessment were high ( or ), with the exception of the indicator on developing a health budget decision-making framework in line with economic priorities. This core health-financing indicator was given a mid-level score of. Country (b) Participant B from Country reported increased levels of confidence across all 10 indicators over the course of the program. 16

18 Figure 1: Comparison of individual competency scores Country (b) Competency assessment - Country (b) 1. Develop a health budget decision-making framework. Identify opportunities for more effective and efficient. Lead efforts to strengthen public service delivery. Make the argument for prioritizing investment in. Establish health budget performance measures and 6. Develop strategies for improved efficiency and value 7. Structure a public sector funding package to 8. Identify fiscal space in the health budget including 9. Negotiate with private sector investment partners to 10. Identify risks to effective implementation and Baseline Follow up Whereas the scores provided at the baseline assessment ranged from 1 to, the scores provided in the follow up assessment were all or. Particularly large improvements were noted on structuring a public sector package to strengthen the health sector (1 ), and negotiating with private sector investment partners to strengthen the health sector ( ). What is likely to change? Interviews were held with a sub-set of seven participants on the final day of the Forum in order to get their views on the value of the program and find out how their learning is likely to impact on their jobs. The interviewees came from Countries 1,,, 6, 7, 8 and 9. Six of the interviewees were finance ministers and one was a deputy minister of economic development in the ministry of finance. The Forum clearly succeeded in affirming the importance of national health in economic development: These discussions have re-emphasised that economic growth without better health in the population is not sustainable. It s the full package health, education, infrastructure are intertwined. These are the priorities in our economic recovery and stimulation plan. (Country 9) We have to talk about the living conditions in small towns and I now understand there are ways of dealing with this issue through primary health care and training people at local level to provide basic health services to the population. (Country ) 17

19 When asked what they found most useful about this Forum, the interviewees mentioned the following issues: Leadership with or without authority, leading by example, articulating goals and motivating people. How to finance the health sector. How to structure a budget and manage resource allocation in government this was particularly pertinent for a finance minister who was new in her post. On Monday I have to finish the budget to present to Parliament in a couple of weeks. It has given me ideas on how to structure the budget and I will probably step on a lot of toes. But I have to ask the questions is it effective, efficient, etc? (Country 7) The impact of wastage on planned outcomes, and hence the importance of efficiency and effectiveness in budgetary spend: There s a lot of wastage. We could do much more with the funding and capital projects, which need to be consolidated. For this we need efficiency, effectiveness and universal health coverage. (Country 6) The importance of accountability in how budgets are spent: Accountability is very pertinent we have to find a way of stopping the leaks. (Country 7) A number of the interviewees mentioned the value of learning from the experience of other countries the Malaysia experience of strategy development, action planning and implementation was cited as being particularly valuable, as was Country 7 s experience. Coming together with people who face the same issues or who have been through similar experiences within the same constraints it makes you feel there are people out there and your situation is not unique; it s not just you. (Country ).1 Impact on the finance minister s job The key change that most of the interviewees plan to make is to work more closely with the health minister in their country and to discuss how health expenditure can be prioritized to be more effective. I will improve the interaction between the ministries of finance and health. We must meet more often than our annual discussion about the health budget. (Country 8) I ll talk to the health minister and the planning minister to ensure the budget reflects the priorities for national development. (Country ) We need to see areas of common purpose. We need to think about the massive amounts of resources given to health and how to redistribute them e.g. to address a shortage of medicines, professional staff and the general delivery of health facilities. (Country 6) Another noticeable change was the way the finance ministers now view their roles in government. Not do my job differently, but do it better. (Country 8) Not do things differently, but to set out goals and how I want to get to them. Focus, and let me try to achieve this in a certain time frame. (Country ) I will have weekly meetings (I used to, but there is always a lack of time) and work more across government to understand their grievances before they come to us. How can we help 18

20 with procurement and cash plans; what are their expectations e.g. in terms of Ebola? Communication matters as much as the policy you write. (Country 9) One finance minister mentioned two ways in which he immediately intends applying some of the ideas discussed at the Forum: Right now in my country there is a connection between these topics and our work e.g. the President asked me two weeks ago to present a project on how to manage taxes on tobacco and alcohol, and that was one of the presentations we had here! So I now have a lot of good information to present to the President. Next week we also have a new reform to be discussed in Congress on universal health care and that was a very important topic to discuss here. So I now have more ideas to better prepare our proposal. (Country 1). Challenges likely to be faced As might be expected, resource mobilization was cited as a challenge by a number of interviewees, but it seems that the Forum was successful in presenting approaches that would enable the ministers to make better use of the resources at their disposal (by reprioritizing areas of expenditure, working more efficiently, etc) and generating additional financial resources. As Minister of Finance I ll always have the challenge of resources, so I need to think of creativity, efficiency, responsibility and transparency. We now have examples of what we can do with transparency and efficiency. We must work as a team, be very coordinated, and participate more in all the goals that each secretary has, especially health care. With better health, education and productivity our country can have economic growth and greater prosperity. (Country 1) We have to reprioritze to get the most value for money and get the results we want. (Country 9) Our resources are not that much, so we have to make sacrifices. Education and health have always been top priorities, but we need to rearrange the priorities [for expenditure]. HIV is a huge priority Country 7 has moved from being third to second [in the world] so we have to focus on that. We don t have a problem with malaria; we have a problem with TB. So realigning the existing funds is more important than asking for more money. (Country 7) Now I can see how to make more funds available for health e.g. through a tobacco tax. I will discuss this strategy with the minister of health in relation to their needs. (Country 8) More surprising was the view expressed by two interviewees that their greatest challenge was not resources, but how to use them. A lot of public health in Country is better funded that it seems. There s a lot of external aid that comes in that is off budget e.g. from USAID and other agencies for HIV, but it s not part of the budget. So there s more money in there than appears to be the case. We need to do some business planning in the health sector health is all about people s lives, but we need facts and figures, and I got a good set of facts and figures here, and methodologies. (Country ) 19

21 We have enough financial resources. 1 If our resources are well structured, they could benefit the majority of the population and it is therefore for now not necessary to think about additional resources. We may need to do so later in terms of the challenges of treating HIV we have one of the world s highest incidences of HIV and the Global Fund has come to our rescue. But they come as matched funds 60/0. (Country 6). Prospects for collaboration between finance and health ministries All the interviewees were positive about the prospects for close collaboration between themselves and their counterparts in the health ministries. Collaboration is key for health and all sectors, otherwise you refuse requests for more money because you don t understand where they are coming from and they don t understand where you re coming from. That can help improve efficiency. I had do so with the ministry of education: they describe their outcomes and plans, so we understand the education sector well and that helps make improvements. (Country 8) We have to spend 80% of the time on strategic work. I took notes. One change is to have a dinner/breakfast once a week with a sectoral minister e.g. social development, including the health minister, and the minister of infrastructure and economics. So I have to coordinate better with them to be more productive and more helpful to them and the country. I will promote those meetings so I can give better support. In September we present the budget to Congress, so it s a good time to coordinate in the preparation. (Country 1) One minister reflected on the importance of working with their staff to develop productive working relationships between the ministries: Things could go wrong with the staff in our ministries the finance ministry staff feel superior to other ministries and the others feel subordinate. So we have to ensure that the goals are the same for all to improve the livelihoods of Basotho. We have to change the mindset of our staff rather than the ministers. (Country 7) In the case of Country 9, the finance minister pointed out that the Ebola crisis had brought the two ministries much closer together: We re already in collaboration. Especially during the crisis the ministry of finance led a team to health to look at the health investment plan we had an office there so people didn t have to come to us. Now the health plan has been completed, it has been costed, so we know the financing gap the health plan beyond Ebola and now we re trying to see how to finance that gap at the World Bank/IMF meeting. (Country 9) One minister stressed the need for collaboration between health and finance to be practical so as to improve public health. He was one of the participants whose health minister had already attended a 1 The following was mentioned as an illustration of the availability of resources for health: Our government is so socially oriented that there are funds set aside to provide for treatment outside, in South Africa, especially for treating civil servants. It s a huge fund, even for treating the general public, but it has not been well organised in the sense that there are no specific procedures on how to apply for the fund. It s subjective and those who successfully benefit from the Fund can easily exploit loopholes and the poor can t benefit from it. 0

22 MLIH Forum and felt that they would now be on the same page in understanding how to make health spending more effective.. Other suggestions When asked about the length of the Forum, all the interviewees agreed that the three-day period was the right length of time. Only one person felt that it could have been a half day shorter. All the respondents commented on the intensity of the programme and the pace of work, but in general they felt that this was necessary to make good use of the time they had available. Some felt that you sign up you accept and know what the programme will look like and I agreed to participate, so one needs to sacrifice time for an intensive programme. Another thanked the organisers, and Dr Michael Sinclair in particular, for mobilizing the best resource people in each field. For me it was extraordinary. I ve learnt a lot and the duration doesn t really matter. It was necessary to be strict in organizing and scheduling and I would be happy to keep working with this team to see how we can change things in my country. (Country ) One person commented that she had been away from her country for a long time because of first attending the World Bank meetings in Washington DC, but she understood that running the two events in tandem helped to save costs. Other suggestions were that it would be helpful to have health and finance ministers both participating in the same Forum so that they could discuss the implications of the different approaches for their country otherwise the one complains about the other. One person suggested that the Forum could invite the health and finance ministers from the same countries and then also have health and finance ministers attending from different countries. Another suggested that the annual meeting in October would be a good opportunity to bring the two ministries together from each country. Some of the interviewees felt that more time is needed for participants to interact during the refreshment breaks. This would help establish better links between individuals who face similar issues and challenges. Another suggestion was to include more examples of how ministers had overcome difficulties in relation to health financing and health systems strengthening. o o o 0 o o o 1

23 Annexure 1 Ministerial Forum for Finance Ministers Program Ministerial Forum for Finance Ministers Loeb House, Harvard University April 19-, 01 Agenda All sessions will be conducted as interactive discussions involving all participants led by senior Harvard Faculty and the Expert Resource Group with the goal of facilitating shared experiential learning. Participants are not required to make any formal presentations. Sunday, April 19 :00pm :0pm Ministers Meet in Hotel Lobby for transfer to Harvard s Loeb House Welcome and Introduction Michael Sinclair, Executive Director, Ministerial Leadership in Health Program, Harvard University 6:00 7:00pm A Framework for Finance Ministers: Health Budget Priority Setting and Performance Measures Rifat Atun, Professor of Global Health Systems, Harvard University 7:00 7:0pm Facilitated Group Work Ministers Define Personal Leadership Vision and Map Budget, Priorities, Constraints and Opportunities Michael Sinclair Saad Rizvi, Delivery Associates, UK 7:0pm Monday, April 0 7:1am Working Dinner Ministerial Leadership: Defining a Legacy by Getting Things Done Michael Barber, former Director Prime Minister s Delivery Unit, UK Hon. Idris Jala, Minister in the Office of the Prime Minister & Director, Performance Management Development Unit (PEMANDU), Malaysia Ministers Meet in Hotel Lobby for Transfer to Harvard s Loeb House 7:0 9:0am Working Breakfast Characteristics of Transformational Leadership Marty Linsky, Harvard Kennedy School 9: 11:00am Transformational Leadership II Marty Linsky 11:00 11:0am Refreshment Break