PUNTLAND GOVERNMENT OF SOMALIA MINISTRY OF HEALTH Health Financing Strategic Plan - DRAFT January 2016 December 2017
PREFACE The Health Financing Strategic Plan (HFSP) is an important step towards building the government s capacity to improve access to health services for the people of Puntland. This plan will improve delivering and the allocation of more cost-efficient service in achieving the Health Sector Strategic (HSSP) priorities. However, there is quite ambiguity of information on health funds sources and as well as how it managed in Puntland to help the policy makers and stakeholders for better evidence based decisions. it assumed that the country has been overwhelmed with the burden of unacceptably high out of pocket expenditure at all levels(more than 80%), substantially a low government spending on health (around 6% of government spending), and absence of health insurance programs. Furthermore, there is currently no consolidated figure of the resource envelope for health. Most external financing is organised bilaterally (rather than being pooled ) to support disease-specific interventions. And this will require more than just increased financial resources for health; it will require improved ways of organizing resource mobilization, allocation and expenditure in order to obtain the maximum value for money to ensure equitable and sustainable financing and financial protection against health expenditures for the entire population. This plan is the cornerstone and the guiding principle of the proposed health care financing strategy towards achieving the First National Health Accounts (NHA), and the Public Expenditure Tracking and Facility Surveys (PETS). It will provide an overview of the vision, and the goals, followed by the strategic objectives, each with their associated strategic interventions that respond to the goals of health financing in Puntland. It attempts at providing the framework and direction for increasing the level of funding for health, ensuring an equitable distribution of the health financing burden, improving access to essential health services, reducing the incidence of catastrophic health care expenditures and improving quality and efficiency of service delivery.
ACKNOWLEDGEMENT The Health Financing Strategy has been developed after consultation meetings with health partners and stakeholders. The development was through a participatory process led by Planning and Policy Development Director under the full support and proactive guidance of the Ministry of Health. The policy prescriptions have been applied after the development of the First Health Sector Strategic Plan (HSSP) 2013-2016 which works towards realization of greater ownership and stewardship in health system and financing. Since the beginning of the development process of the strategy document, the Director General Dr. Abdiriak H. Hassan actively contributed to the drafting and in carrying forward the consultation process. He has taken the process to its logical conclusion. The Planning and Policy Director under the stewardship of Mr. Abdiriak H. Isse, have drawn up the road map for developing the strategy.
1. VISION OF THE NATIONAL HEALTH FINANCING STRATEGY In line with the overall Health Sector Strategic Plan (HSSP), the vision of the Ministry of Health is to improve the health and wellbeing of all people of Puntland through a provision of high quality health services in equitable and sustainable manner for health financing mechanisms 2. MISSION STATEMENT The Mission of the health financing strategy is to strengthen financial risk protection and extend health services and population coverage, with the aim to achieve universal coverage by: 1. Expanding population access to health access and health care services, particularly to the poor and marginalized groups; 2. Improving the stewardship and leadership of the government in health system; 3. Introduce the bottom-up health planning and budgeting from facility to regional to the central level; 4. Introduce the Performance-Based Financing (PBF) approach for better utilization of health services; and 5. Improving predictability and allocation of funding streams through the establishment of National Health Accounts (NHA), and the Public Expenditure Tracking and Facility Surveys (PETS). 3. PRINCIPLES The HCF Strategy has been developed in light of the following principles stipulated in the National Health Sector Strategic Plan developed in 2012: 1. Ensuring access; 2. Improving quality; 3. Enhancing equity; 4. Attaining sustainability; 5. Promoting accountability and transparency; 6. Generating efficiency; 7. Advancing simplicity; and 8. Results-oriented culture. 4. ROLES OF STAKEHOLDERS The proposed strategy envisages an increased engagement and strengthened stewardship role of the Ministry of Health. The Ministry needs to assume diversified roles of steward, promoter, provider, contractor and regulator. It requires developing ethical standards for health service delivery, enforcing patient s charter of rights, formulation of legal and regulatory norms, developing standard treatment guidelines and management protocols for the national health benefit package so as to govern quality, quantity and price, and proactively promoting the case for sufficient resources for the health sector. NGOs also provide curative care through clinics and hospitals which is relatively a recent phenomenon. The health care financing strategy aims to maximize the complementary role of the NGOs and the private sector through Public Private Engagement.
Development Partners (DP) play an important role by providing financial and technical assistance in the health sector. The proposed strategy envisages continuing DP engagement. The proposed strategic interventions and actions will be designed in such a way so as to increase people s engagement and participation. 5. CHALLENGES OF HEALTH FINANCING IN PUNTLAND 5.1. Institutional Reform Most of health service delivery in Puntland is largely conducted by NGOs, funded by the International Donors, and managed by the MOH, but there is dedicated Unit within the MOH organogram responsible for overseeing these contracts. 5.2. Week National Capacity The current lack of capacity in the area of applied health economics and resource management is quite apparent in all MOH levels. 5.3. Absence of Accurate Health Financing Data and Analysis Almost the key data of the health economics and financing are not in place. Most of the key studies and surveys which is perquisite for better understanding and decision making are not yet been conducted. 5.4. Inadequate Resources in the Health Sector Actual available resources for investment in the health care costs may come from various sources, but apparently that is not sufficient. The government spending on health is almost 6% from the national budget, which equivalent of less than 2M per year and the other international donors contribution is not pooled or consolidated. Most of health expenditure comes from household out-of-pocket. 5.5. Limited Aid Coordination There is lack of harmonization and alignment of strategic and operational investment planning by the Government and developing partners. This includes the vertical programs and donor agency projects which contribute the national health system in various ways but not aligned by the national priorities 6. OBJECTIVES OF THE HEALTH FINANCING STRATEGY To attain a strategic guiding of the health financing in sustainable, equitable, effective and efficient manner, the following are the Puntland health financing objectives: 1. Review of the current organogram of MOH and restructuring in a way that fits a Unit of Health Economics and Finning, to address the importance of health care financing, economics and policy research in strategic planning. 2. Introduce a comprehensive capacity building programs for the senior managers of MOH in applied health economics and financing techniques 3. Conduct the basic surveys of health financing information in Public Health Expenditure and the current EPHS programs 4. Prepare the common ground towards the establishment of National Health Accounts (NHA), and the Public Expenditure Tracking and Facility Surveys (PETS). 5. Explore a health financing system that relies more on local financing and local resources, aligns funding to Puntland s priorities and is based on sound financial management, develop additional local revenues for health through expanding voucher systems, taxing on the harmful substance (cigarettes and Khat), charging
fees for health providers to register, and recovering costs from communities and individuals using public health services. 6. Work closely with the donor community to improve harmonisation of external finance through establishing a more effective government donor planning and consultation process, and increase the level of external funding in health sector and enhance transparency and accountability of donor assistance. 7. PROCESS INDICATORS Proportion of capacity building in MOH in relation to baseline needs assessment; Number of seminars conducted in applied Health Economics; Number of costing studies conducted; Fully established and institutionalized National Health Accounts processes; Number of programs and sub-programs developing and submitting health budgets; Number of established public/private partnerships; and Number of facilities operating under results-based financing. 8. OUTCOME INDICATORS Proportion of out-of-pocket payments in relation to total Health Spending; Per capita government expenditure on Health; External resources for health as a percentage of total health expenditures; Public domestic resources for health as a percentage of total health expenditures; Level of inequity in the provision of health services; and Proportion of health facility revenues covered by a health-financing scheme. 9. STRATEGIC INTERVENTIONS The following provides a general description of the Four intervention components developed to address the primary HF issues in Puntland and to advance the public administration activities of the MOH in this key focus area. This description is followed by a list of intervention components and responsible departments within the MOH, along with specific tasks and targets. STRATEGIC NO.1 MOH INSTITUTIONAL REFORM One of the key important steps towards achieving this strategic intervention is to establish a dedicated Unit for the Health finance within the Ministry of Health. A lot of efforts were made to discuss about the responsibilities and level of representation within the Department of the Policy and Planning. The current organogram of MOH has to be reviewed and restructured in a way that fits a Unit of Health Economics and Finning, to address the importance of health care financing, economics and policy research in strategic planning In late 2015, the MOH has established the HF unit t manage and oversee health project proposals mainly from the international community and recommend actions to the MOH leadership. For the near future, HFU would have the responsibility of working to expand the delivery of the EPHS services in collaboration with international donors, NGOs, the United Nations (UN) and the private sector while strengthening MOH leadership in health resource
management. HFU also held the primary responsibility within the MOH to manage donorrelated contracts including EPHS. STRATEGIC OBECTIVE: Review of the current organogram of MOH and restructuring in a way that fits a Unit of Health Economics and Financing ESSETIAL INDICATORS Health Financing Unit operational and fits with the MOH organogram HFU TOR developed and disseminated HFU staff recruited and incentivized KEY ELEMENTS OF THE REFORM PROCESS Coup of elements have contributed should contribute for the prospective reform in the MOH in Puntland and should be highlighted to inform the international community about mechanisms for building effective and sustainable HFU. In summary, the key elements can be categorized as the following: 1. International collaboration and commitment for financing the HFU, and 2. Evidence-based research and strategy development, STRATEGIC NO.2 HFU CAPACITY DEVELOPMENT STRATEGIC OBJECTIVE Develop capacity of the MOH at central and Regional levels in applied Health Economics, Health Financing, and Resource Management ESSENTIAL INDICATORS Proportion of Capacity Building in MOH in relation to baseline needs assessment; Number of staff trained in Applied Health Economics; Number of seminars conducted in applied Health Economics; and Number of costing studies conducted. Building capacity within HFU is critical to supporting the MOH in health financing and for achieving the goals of the health care financing strategy. Capacity building will be a joint effort between the MOH and various sources of technical support. In this regard, MOH need an external expertise from various donor agencies to develop the unit. These experts will work closely with staff from HFU and Department of finance to develop their capacity. More specifically, the experts will provide capacity development and guidance to the units as follows over the period of the strategy until 2017: Conduct a needs assessment with regard to capacity building in the health financing unit; Develop a ToR for capacity development; Conduct initial seminar with HFU staff on all aspects of applied health financing; Identify data sources and track health financing data; Establish a baseline cultural and community analysis for health financing pilot tests; MOH staff training to pilot test and examine outcomes of health financing initiatives and insurance options; Training of MOH staff on ways to improve strategy costing s from central and regional levels;
Training of MOH staff on the application of health financing data for policymaking; Conduct two workshops on health financing data collection and organization, and health financing analysis techniques; and Develop a brief health financing reference guide specific to implementing health financing initiatives in Puntland STRATEGIC NO.3 INTRODUCING THE BOTTOM-UP HEALTH PLANNING AND BUDGETTING SYSTEM STRATEGIC OBJECTIVE: Conduct the basic surveys of health financing information in Public Health Expenditure and the current EPHS programs To advance an efficient and effective health service delivery system by establishing and making available economic data within both the public sectors ESSENTIAL INDICATORS Number of cost and cost-effectiveness studies conducted; Level of financial management autonomy; Number of programs and sub-programs developing and submitting health budgets; and Level of efficiency in the allocation of health resources. STRATEGIC NO.4 SUPPORT MAPPING HEALTH EXPENDITURE FLOW STRATEGIC OBJECTIVE Prepare the common ground towards the establishment of National Health Accounts (NHA), and the Public Expenditure Tracking and Facility Surveys (PETS). ESSENTIAL INDICATORS Fully established National Health Accounts processes By the end of this Strategic Plan the following structures are well defined to the MOH policy makers, Rigorous classification of the types and purposes of expenditures and of the actors in the health system including households, public and private sector providers, NGOs, UN technical agencies, ad hoc funding (Diaspora funds), etc. Complete accounting of all spending for health, regardless of the origin, destination, or object of the expenditure; and Rigorous approach to collecting, cataloging, and estimating those flows of money
10. DETAILED WORK PLAN FOR 2016 Goal1: Increase MOH Capacity for Health financing Objectives Activities Sub activities Cost Time Frame Better understanding Capacitate Health 1. Review the Unit $5,000 Nov-15 for the Key economic question on health financing Unit TOR 2. Furniture for the $5,000 Dec-15 office of HF unit 3. Develop comprehensive capacity building of MOH staff on applied health economics and financing $30,000 Jan-Mar 2016 Indicators: Finalized TORS; Number of staff trained on health economics; Number of seminars conducted on applied economics Goal2: Mapping Key financial resources in health MOH Publishes source and expenditures on health financing Data for the preparation of National Health Accounts Analysis financial inflows and outflows by: 1. Examining GOVT contribution 2. Donor Contribution $15,000 April-Jun 2016 Indicator: Consolidated report on Health Account Goal3: Introduce the bottom-up health planning and budgeting system
Conduct basic surveys of health financing information in Public Health Expenditure and the current EPHS programs Facility Survey Costing Indicator: Facility based costing introduced 1. ToR for cost analysis 2. Develop Questionnaires on facility costing exercise 3. Analyse the date 4. Share and publish results $60,000 July-Dec 2016 FOCUS AREA FOR THE WORKPLAN Mainstreaming of health financing in HSSP: Health financing strategy shall be mainstreamed in all relevant policies. MoH shall guide other government ministries, departments and the private sector on health issues Evidence-based and forward looking: The implementation of the Health Financing strategy shall be evidence-based, forward looking and take into account emerging trends. Sustainability: This strategy shall provide a framework to support sustainable development in order to address the burden of diseases in a cost effective way. Partnerships: The private sector shall be seen as complementary to the public sector in terms of increasing geographical access to health services and the scope and scale of services provision. REQUIRMENT FOR SUPPORT 1. Work closely with the donor community to improve harmonisation of external finance through establishing a more effective government donor planning and consultation process, and increase the level of external funding in health sector and enhance transparency and accountability of donor assistance. 2. Continued capacity building on health financing through mentorship, training, skill transfer programs and fellowships 3. Secure essential funding/resources for establishing Health financing policy and strategy DELIVERABLES AND TIME FRAME 1. Policy briefs on Key pillars National Health account in place by the 2016 2. Baseline needs assessment of MOH Capacity Building on health finance conducted by the first quarter of 2016 3. EPHS and Non EPHS Facility costing exercise assessment to be available before the end of HSSP 4. Technical Advisory Group established by the first Quarter of 2016