Health Financing in Africa: More Money for Health or Better Health For the Money? March 8, 2010 AGNES SOUCAT,MD,MPH,PH.D LEAD ECONOMIST ADVISOR HEALTH NUTRITION POPULATION AFRICA WORLD BANK
OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA S INNOVATIONS IN HEALTH FINANCING FROM HERE TO THERE
OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA S INNOVATIONS FROM HERE TO THERE
Maternal Mortality Remains Very High in SSA 1000 900 900 Per 100,000 live births 800 700 600 500 400 300 200 100 150 500 45 0 East Asia & Pacific South Asia Sub Saharan Africa China Source: World Development Indicators 2007 #2
Most countries in SSA are off track to reach MDG5
Most SSA countries spend less than US$50 per capita on health
Some Countries Have Problems Accommodating even a Basic Package of Services
More than half of health expenditures in SSA are private
Out of Pocket Spending dominates private financing in most countries
External aid is an important source of health spending in Sub-Saharan Africa External aid as % of total health spending (2002) 20 Percent of total health expenditure 18 16 14 12 10 8 6 4 2 0 East Asia & Pacific Eastern Europe & Central Asia Latin America & the Caribbean Middle East & North Africa South Asia Sub-Saharan Africa Region
Six years to the MDGs The MDGs horizon is six years away: what are the low hanging fruits? What is most effective? What can be quickly scaled up? The health sector does not produce results. Why is it? It does not need to be so: some countries are doing much better than others.. Some countries give very little priority to health..why? What needs to be addressed? #2
Critical issues to be addressed Fragmentation and donors processes disconnected from country processes Planning and Budgeting not based on evidence and analysis of country specific constraints to delivering high impact interventions Public money benefits richer groups Public Financial Management frontline providers do not have resources (PETS) Post colonial civil service models reach their limits. Dramatic lack of linkage between performance and incentives..
OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY: RWANDA S INNOVATIONS FROM HERE TO THERE
Rwanda A small country in Central Africa Genocide in 1994 In 2005, 4/10 births attended by a health professional. Infant Mortality : 86 per 1,000 HIV : 3.1% Source: Rwanda 2005: results from the demographic and health survey. 2008. Studies in family planning, 39(2), pp. 14
Rwanda Shortage of human resources for health services No cash resources in health facilities Low levels of productivity and motivation among medical personnel Low user satisfaction & poor quality of service leading to low use.
Rwanda has undertook major reforms to strengthen accountability of all institutional and individual actors for MDGs related results...
..through a shift of paradigm.. - Fiscal Decentralisation with strong governance structures and community participation. - IMIHIGO: Performance contracts between President of the Republic and mayor of Districts; - PBF: Performance Based Financing; - CBHI: Community Health Insurance; - Autonomy of health facilities, including hiring and firing of health personnel;
Strengthening accountability in the health sector in Rwanda NATIONAL GOVERNMENT PERFORMANCE BASED, CASH AND IN KIND INVESTMENT INPUT SUBSIDIES TRANSFERS Umushyikirano, Citizen Report Cards, Ombusdman VOICE LOCAL GOVERNMENT CLIENT POWER Performance CONTRACTS Clients / Citizens COMMUNITY GOVERNANCE COMMUNITY HEALTH INSURANCES Mutuelles AUTONOMOUS FACILITIES PROVIDERS COMMUNITY HEALTH WORKERS PROVIDERS
Results show Rwanda is now back on track towards the health MDGs Under five mortality trends with MDG target for 2015 250 1990 level U5MR per 1,000 200 150 100 50 MDG target for 2015 Observed Trends since 1998 0 1999 2001 2003 2005 2007 2009 2011 2013 2015 Trends required to reach the 2015 target
All income groups benefit although inequities still persist Under five mortality trends by income quintile (2005-2007) 250 U5MR per 1,000 200 150 100 211 161 195 149 170 132 204 141 122 84 50 0 Poorest Quintile 2 Quintile 3 Quintile 4 Richest DHS 2005 DHS 2007 Source: DHS 2005 and 2007.
Rwanda: Coverage with MDGs High Impact Interventions increases % 100 90 80 70 60 50 40 30 20 10 0 2000 2007 % delivered in a health facility TOTAL DPT3 (%) Currently Using any modern FP method (%) % U5 who slept under an ITN the past night
Increase in utilization of assisted deliveries Trends in assistance at delivery : Years 2000, 2005, 2007. Percentage (%) of women delivered by a health professional
Decentralization Administrative, fiscal and financial decentralization has provided large sums of money to local levels of government and given them much flexibility by providing them with block grants Am ount in RW F Fiscal and Financial Decentralization 70,000,000,000 60,000,000,000 50,000,000,000 40,000,000,000 30,000,000,000 20,000,000,000 10,000,000,000 0 Disbursed 20 02 Disbursed 20 03 Disbursed 2004 Disbursed 2005 Year B udget 200 6 Projected 2007 Transfers to Districts CDF Transfers to Provinces
Total health personnel in publicly funded facilities has almost doubled in 3 years Source: Public Expenditures Review Rwanda; 2005
Financing has more than tripled in four years (going from USD 7.5 to 30.3 millions, of which the PBF has grown more than tenfold from USD 0.8 to 8.9 millions) Source: Public Expenditures Review Rwanda; 2005
Health Insurance in Rwanda Micro-Insurance model with two levels of re-insurance funds Tax subsidy and crossusbidy from formal sector insurance Rapid increase in enrollment from 7% in 2003 to 91% in 2008 Mutuelle enrollment significantly improves access to health care at all income levels, including the poorest and reduces inequality in access, particularly among the top four quintiles. Mutuelle enrollment significantly reduces the risk of catastrophic health expenditures.
Rwanda: Scaling up of community health insurance Proportion of individuals enrolled in health insurance % 90 80 70 60 50 40 30 20 10 0 2002 2003 2004 2005 2006 2007 2008 Source: MOH Rwanda; 2005 EICV 2005
At all income levels, those enrolled in mutuelles are much more likely to use health services. % use of reproductive health services 100 90 80 70 60 50 40 30 20 10 0 8 27 11 93 96 Use of contraceptives, 15-49 years At least one ANC Delivery assisted by skilled professional None RAMA Health mutuelle 97 35 77 42 DHS 2005
Performance-based Financing (PBF) 29 Developed after extensive piloting from 2001-2005 Objectives Focus on maternal and child health as well as communicable diseases (MDGs 4 & 5) Increase quantity and quality of health services provided Increase health worker motivation Financial incentives to providers to see more patients and provide higher quality of care Operates through contracts between Government Health facilities providing services
Table 1: Output Indicators (U s) and Unit Payments for PBF Formula OUTPUT INDICATORS Amount paid per unit (US$) Visit Indicators: Number of 1 curative care visits 0.18 2 first prenatal care visits 0.09 3 women who completed 4 prenatal care visits 0.37 4 first time family planning visits (new contraceptive users) 1.83 5 contraceptive resupply visits 0.18 6 deliveries in the facility 4.59 7 child (0-59 months) preventive care visits 0.18 Content of care indicators: Number of 8 women who received tetanus vaccine during prenatal care 0.46 9 women who received malaria prophylaxis during prenatal care 10 at risk pregnancies referred to hospital for delivery 1.83 11 emergency transfers to hospital for obstetric care 4.59 12 children who completed vaccinations (child preventive care) 0.92 13 malnourished children referred for treatment 1.83 14 other emergency referrals 1.83 0.46
Delivery at the health facility increased overall in Rwanda, but 7% more in PBF facilities between 2006-2008. 31 Proportion of of institutional deliveries 60.0 50.0 40.0 30.0 36.3 34.9 55.6 49.7 Baseline (2006) Follow up (2008) Control facilities Treatment (PBF facilities) 7.3 % increase due to PBF
In the last years, PBF has increased prenatal care quality significantly 32 Standardized Prenatal effort score 0.20 0.15 0.10 0.05 0.00 0.05 0.10 0.15 0.10 0.13 0.15 Baseline (2006) Follow up (2008) Control facilities 0 15 % Standard deviation increase due to PBF Treatment (PBF facilities)
OUTLINE MORE AND BETTER MONEY: WHERE ARE WE? A TALE OF ONE COUNTRY.. RWANDA S INNOVATIONS FROM HERE TO THERE
MDGs are ambitious: scaling up will be challenging to implement SSA Countries require increased and better allocated domestic and external funding for strengthening their national health systems in order to achieve the MDGs. Most resources are to come from countries contributions: need for domestic advocacy to raise attention to national budgeting processes Need to channel private spending into risk pool Importance for external aid to be catalytic: need to focus on results and efficiency gains
Evolution of Health Financing Systems Low Income Countries Patient Out-of of- Pocket Social Insur Gov t Budget Community Financing Middle Income Countries Priv. insur Patient Out- of-pocket Social Insur Gov t Budget High Income Countries Government Budget/MOH Patient Out- of-pocket National Health Service Social Health Insurance Private Insurance Source: Modified from A. Maeda
Making private money more efficient: Health Insurance As out of pocket spending has been growing recently, the need for pooling emerges as a main policy priority in SSA Two African countries (Ghana and Rwanda) are achieving ground breaking success on health insurance pushing the limits of the innovation frontier These countries demonstrate that it is possible to achieve rapid scale up of healh insurance with actual effect on health utilization and income protection
Making public money more efficient: Results Based Financing Purchasing of results and outputs replacing input based financing Promising results in Afghanistan, Burundi, DRC, India, Haiti, Nepal, Zambia Adopted and initiated in Benin, Ghana, Eritrea, Ethiopia, Scaled up in Rwanda and positive results from rigorous Impact Evaluation
Conclusion With the MDGs finish line in view, a strong dialogue between MOH and MOF is more needed than ever Dialogue can be centered around the production of results: the health sector can do it Both supply and demand side financing need to be tapped Some hard issues need to be tackled: budget reform, a new vision for public workers, PFM reform around decentralization, autonomy and results focus
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