v15 of report - universal health coverage partnership · abbreviations&!...
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“I!regard!universal*health*coverage!as!the!single!most!powerful!concept!that!public!health!has!to!offer.!It!is!inclusive.!It!unifies!services!and!delivers!them!in!a!comprehensive!
and!integrated!way,!based!on!primary!health!care.”!
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Dr!Margaret!Chan,!WHO!DirectorBGeneral!
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Table of Contents Abbreviations................................................................................................................................................... 4
Background and Introduction .......................................................................................................................... 8
Specific objectives and estimated results ......................................................................................................... 9 UHC Partnership results and impact ............................................................................................................... 1 4 Overall achievements and lessons learned .................................................................................................... 1 7 Principal challenges ....................................................................................................................................... 2 1 Conclusion and Way forward ........................................................................................................................ 2 2 Country reports .............................................................................................................................................188 Burkina Faso ...................................................................................................................................26 Cape Verde ....................................................................................................................................34 Chad ...............................................................................................................................................39 Democratic Republic of the Congo ..................................................................................................61 Guinea ............................................................................................................................................67 Liberia ............................................................................................................................................77
Mali................................................................................................................................................84 Republic of Moldova ......................................................................................................................90 Mozambique ...............................................................................................................................102 Niger ............................................................................................................................................108 Senegal .........................................................................................................................................113 Sierra Leone .................................................................................................................................122 South Sudan .................................................................................................................................125 Sudan ...........................................................................................................................................131 Timor Leste ..................................................................................................................................133 Togo .............................................................................................................................................140 Tunisia .........................................................................................................................................149 Vietnam .......................................................................................................................................162 Yemen ..........................................................................................................................................178
Visibility and communications ...................................................................................................................188
Abbreviations AFD: Agence Française de Développement AFRO/IST: World Health Organization Africa Regional Office/Inter-‐country Support Team AOP: Annual Operational Plan (Liberia) BCE: Bureau de la Coopération et des Etudes (Tchad) CAMEG-‐Togo: Centrale d’Achat de Médicaments Essentiels Génériques du Togo CAMES: Conseil Africain et Malgache de l'Enseignement Supérieur CBHI: Community Based Health Insurance CCM: Comité National de Coordination du Fonds Mondial de lutte contre le Sida, la Tuberculose et le Paludisme CCS: Conseil Communal de Santé (Niger) CDMT: Cadre de Dépenses à Moyen Terme CDS: Conseil Départemental de Santé (Niger) CE: Commission Européenne CHPP: Country Health Policy Process CHR: Centre Hospitalier Régional CHU: Centre Hospitalo-‐Universitaire CMU: Couverture Maladie Universelle CNP: Comité National de Pilotage (RDC) CNS: Comptes Nationaux de la Santé CNS: Conseil National de Santé (Niger) COIA: Commission on Information and Accountability for Mother and Child Health (Tchad) CONAMED: Commission Nationale du Médicament CPA: Centrale Pharmaceutique d’Achat (Tchad) CPS: Cellule de Planification et des Statistiques CRS: Conseil Régional de Santé (Niger) CRVS: Civil Registration and Vital Statistics (Timor-‐Leste) CSD: Cadre Sectoriel de Dialogue CSS: Conseil Supérieur de la Santé CSU: Couverture Sanitaire Universelle CT CSU: Comité Technique d’Elaboration de la Stratégie Nationale de la CSU (Tchad) CTNS: Conseil Technique National de Santé (Niger) CTRS: Conseil Technique Régional de Santé DES: Diplôme d’Etudes specialises DFID: Department for International Development (South-‐Sudan) DGAS: Direction Générale des Activités Sanitaires (Tchad) DGASR: Direction Générale de l'Action Sanitaire Régionale (Tchad) DGPL: Direction Générale de la Pharmacie et du Laboratoire (Tchad) DGRP: Direction Générale des Ressources et de la Planification (Tchad) DHIS: District Health Information Software DHS: Demographic and Health Survey (Liberia) DOSS: Direction de l’Organisation des Services de Santé (Tchad) DPs: Development Partners DPML: Direction de la Pharmacie des Medicaments et du Laboratoire (Tchad) DPS: Division Provinciale de la Santé (RDC, Togo) DRC: Democratic Republic of Congo
DRH: Direction des Ressources Humaines DRS: Direction Régionale de la Santé (Togo) DS: District Sanitaire DS: Dialogue Sociétal (Tunisie) DQS: Data Quality Survey (Contrôle de Qualité des Données) DUE: Délégation de l’Union Européenne EGS: Etats Généraux de la Santé EMRO: The WHO Regional Office for the Eastern Mediterranean EPAT: Equipe Polyvalente pour l’Accompagnement Technique (RDC) EPH: Etablissement Public Hospitalier ER: Estimated Result EU: European Union EVD: Ebola Virus Disease FED: Fonds Européen de Développement FFM: Fonds Français Muskoka FMS: Financial Management System (Sierra Leone) GAR: Gestion Axée sur les Résultats GFTAM: Fund to fight AIDS, TB and Malaria GIZ: Deutsche Gesellschaft Für Internationale Zusammenarbeit GSM: Global Management System GTC: Groupe Technique Consultatif (Tchad) HCF: Health Care Facilities HF: Health Financing HFS: Health Financing Strategy HHA: Harmonisation pour la Santé en Afrique HMIS: Health Management Information System (Timor-‐Leste) HPG: Health Partnership Group (Vietnam) HQ: Headquarters HRH: Human Ressources for Health HSC: Health Sector Cordination HSCC: Health Sector Coordination Committee (Liberia) HSS: Health System Strengthening HTA: Health Technology Assessment (Tunisie) ICD: MoH Department of International Cooperation (Vietnam) IHP+: International Health Partnership ILO: International Labour Organization INAM: Institut National d’Assurance Maladie (Togo) INGO: International Non-‐governmental Organizations INS: Institute of Health Sciences INASanté: Instance Nationale de l’Accréditation en Santé (Tunisie) IS: Inspection Générale (Tchad) IST: Infections Sexuellement Transmissibles IST/WA: Inter pays OMS de l’Afrique de l’Ouest JARH: Joint Annual Health Review (Vietnam) JANS: Joint Assessment of National Strategy (Liberia, Mali, Vietnam) JFA: Joint Funding Arrangement (Sierra Leone) LUX: Luxembourg M&E: Monitoring and Evaluation
MEG: Medicaments Essentiels Génériques MoF: Ministry of Finance MoH: Ministry of Health MoHS: Ministry of Health and Sanitation (Sierra Leone) MoHSW: Ministry of Health and social welfare (Liberia) MoLabour: Ministry of Labour MoLG: Ministry of Local Government MoPHP: Ministry of Public Health and Population (Yemen) MS: Ministère de la Santé MSP: Ministère de la Santé Publique MVE: Maladie à Virus Ebola NCDs: Non-‐communicable Diseases NGO: Non-‐governmental Organization NHA – National Health Accounts NHCCC: National Healthcare Coordinating Committee (Liberia) NHPS: National Health Plans and Strategies NHPSP: National Health Policies, Strategies and Plans NHSSP: National Health Sector Strategic Plan NHSSP-‐SP: National Health Sector Strategic Plan – Support Project NHSWPP: National Health and Social Welfare Policy and Plan (Liberia) NPO: National Professional Officer OASIS: Organization Assessment for Improving and Strengthening Health Financing OCHA: Office for the Coordination of Humanitarian Affairs ODA: Official Development Assistance (Vietnam) OMD: Objectifs du Millénaire pour le Développement OMS: Organisation Mondiale de la Santé ONG: Organisation Non-‐gouvernementale OOP: Out-‐of-‐pocket Payments P4H: Providing for Health -‐ Initiative de protection sociale en santé PAA: Plan d’Action Annuel (Niger) PACCOM: The People’s Aid Coordinating Committee PAO: Plan d’Actions Opérationnel (RDC, Yemen) PAZD: Programme d’Appui aux Zones Défavorisées (Tunisie) PEV: Programme Elargi de Vaccination PDS: Plan de Développement Sanitaire PDDSS: Plan Decennal de Developpement Sanitaire et Social (Mali) PDSC: Plan de Développement Sanitaire des Cercles (Mali) PHI: Private Health Insurance PNDS: Plan National de Développement Sanitaire PNS: Politique Nationale de Santé PNUD: United Nations Development Programme (Programme des Nations Unies pour le Développement) PRA: Pharmacie Régionale d’Approvisionnement (Tchad) PRD: Plan de Développement des Directions Régionales PRDS: Plan Régional de Développement Sanitaire PRISM: Performance du Sytème d’Information de Gestion de Routine PRODESS: Programme de Développement Sanitaire et Social (Mali) PSM: Politique Sanitaire en Mouvement (Togo) PSSC: Plan Stratégique de Santé Communautaire
PTF: Partenaire Technique et Financier RCPAS: Réseau des Champions en Plaidoyer pour un Financement Adéquat de la Santé (Niger) RDQA: Routine Data Quality Assessment (Liberia) RH: Ressources Humaines RMNCAH: Reproductive Maternal Newborn and Child and Adolescent Health RSS: Renforcement des Systèmes de Santé SARA: Services Availability and Readiness Assessment SDC: Swiss Agency for Development and Cooperation SG: Secretariat Général (Tchad) SHI: Social Health Insurance SNFS-‐CSU: Stratégie Nationale de Financement de la Santé vers la Couverture Sanitaire Universelle (Togo) SNSC: Stratégie Nationale de Santé Communautaire (Tchad) SN CSU: Stratégie Nationale de Couverture Sanitaire Universelle (Tchad) SNPS: Stratégie Nationale de Protection Sociale (Tchad) SO: Specific Objective ST CCSS: Service Technique du Comité de Coordination du Secteur de la Santé (Guinée) SWAP: Sector-‐Wide Approach TA: Technical Assistance TB: Tuberculose TDR: Termes de Référence TWGs: Technical Working Groups (Vietnam) UC: Universal Coverage UE: Union Européenne UHC: Universal Health Coverage UN: United Nations UNFPA: United Nations Funds for Population Agency (Fonds des Nations Unies pour la Population) UNHCR: United Nations High Commissioner for Refugees (Haut-‐Commissariat des Nations-‐Unies pour les Réfugiés) UNICEF: United Nations of International Children’s Emergency Funds (Fonds des Nations Unies pour l’Enfance) USAID: United States Agency for International Development (Agence Américaine pour le Développement International) USD: United States dollar VHPO: Vietnam Health Project VIH: Virus de l'immunodéficience humaine WB: World Bank WCO: World Customs Organization WHF: World Heart Federation WHO: World Health Organization WHO FCTC: WHO Framework Convention on Tobacco Control
Background and Introduction In 2011, the European Union, Luxembourg and WHO Universal Health Coverage Partnership (“UHC Partnership”) began targeted support on policy dialogue on national health policies, strategies and plans in 7 countries; this was extended in 2013 to 19 countries, with additional emphasis on health financing and aid effectiveness through the International Health Partnership (IHP+).Based on 3 major pillars (UHC, IHP+ and NHPSP Policy Dialogue), the UHC Partnership aims at building country capacities
for the development, negotiation, implementation, monitoring and evaluation of robust and comprehensive national health policies, strategies and plans, with a view of promoting UHC, people-‐centred primary health care, health in all policies and the implementation of the Aid/Development Effectiveness agenda.
This report will cover the calendar year 2014 which represents Year 3 of the Partnership for the Phase I EU-‐funded countries (Moldova, Liberia, Sierra Leone, Sudan, Togo, Tunisia, and Vietnam) and Year 2 of the Partnership for Phase II EU-‐funded countries (Chad, DRC, Guinea, Mozambique, South Sudan, Timor-‐Leste, and Yemen) and Luxembourg-‐funded countries (Burkina Faso, Cape Verde, Mali, Niger, and Senegal). Overall, the Partnership’s experience of 3 years on the ground has brought about solid, credible results in most countries, despite setbacks and difficulties such as conflict and an Ebola outbreak – details are presented in the following sections of the report. An exemplary depiction of the Partnership’s work in its focus area of Universal Health Coverage is shown in the diagram below:
More information on the genesis of the Partnership as well as country-‐specific documents can be found at www.uhcpartnership.net.
“The participating organizations, such as the World Health Organization, act as advisors. WHO also aims to stimulate conversations on health issues between the Ministry of Health and other government entities such as the Ministry of Finance.” – Dr. Sall, Health Economic Advisor at WHO Senegal.
Specific objectives and expected results
The 2014 activities undertaken in each of the 19 countries were determined during the inception phase, and outlined in the Country Road Maps. These activities are listed generically in the WHO-‐EU action fiche and in the WHO-‐Luxembourg agreement, and are linked to 5 main estimated results and 2 specific objectives which are the target of this report1. We briefly describe country examples where the specific objectives have been achieved; the examples are not exhaustive and are meant to demonstrate a few country illustrations only -‐-‐ more details can be found in the country reports.
Table 1
Specific objectives Expected results related to SO 1 & 2
Specific Objective 1: To support the development and implementation of robust national health policies, strategies and plans to increase coverage with essential health services, financial risk protection and health equity; Specific Objective 2: To improve technical and institutional capacities, knowledge and information for health systems and services adaptation and related policy dialogue
ER 1. Countries will have prepared/developed/updated/adapted their NHPSP through an inclusive policy dialogue process leading to better coverage with essential health services, financial risk protection and health equity; ER 2. Countries will have put in place expertise, monitoring and evaluation systems and annual health sector reviews; ER 3. Countries requesting health financing (HF) support will have modified their financing strategies and systems to move more rapidly towards universal coverage (UC), with a particular focus on the poor and vulnerable: ER 4. Countries receiving HF support will have implemented financing reforms to facilitated UC; ER 5. Accurate, up-‐to-‐date evidence on what works and what does not work regarding health financing reforms for universal coverage is available and shared across countries.
1 Specific objective 3 and its linked estimated results are covered in IHP+’s reporting to IHP+ partners, including
Expected Result 1 Countries will have prepared/developed/updated/adapted their NHPSP through an inclusive policy dialogue process leading to better coverage with essential health services, financial risk protection and health equity In DRC, the strengthening of the intermediate level of the health system is a key priority in the Health Systems Strengthening Strategy elaborated in 2006. Targeted support through the UHC Partnership was provided to the Provincial Health Departments with the aim of rendering them more functional – this important ‘intermediary’ administrative level often falls through the cracks in both donor and government attention. Districts (health zones in DRC), or the peripheral levels, clearly need support because it is where end users meet the health systems head on. The central level usually enjoys a good chunk of both government and donor support due to its location, political nature, and visibility. The level which is often neglected is the in-‐between level of the province. In a country the size of DRC, this level is particularly important because it covers an area which could be the size of any neighbouring African country and because the central MoH does not have the staff and resources to be knowledgeable about and adequately support the overwhelming number of over 500 health zones. In order to better operationalize DRC’s NHPSP strategic direction #1 of developing the health zones, it was clear to the MoH that the provincial level had to be strengthened in parallel. The UHC Partnership has been very active in making the provincial level more operational, for example, by supporting the preparation of a government directive on the Provincial Health Department, supporting the finalization of post descriptions for the intermediate level, participating in the recruitment process of the professionals to be appointed in the 26 provinces , and organizing a short training course for the 26 Heads of Medical Provinces.
In Chad, the National Health Development Plan II took a long time to finalize. With the support of the UHC Partnership, this was achieved in late 2013. This Plan II, compared to the former Plan I, is recognized by government and development partners to be of better quality, more country owned, and more likely to be operationalized and implemented. WHO support is credited with this strong improvement; a participatory process and a real dialogue among national and international health stakeholders has taken place and will now be used to support the Plan II implementation and its monitoring and evaluation. In Senegal, several capacity building efforts were made under the UHC Partnership with WHO support to ensure common implementation of the National Health Development Plan by all concerned stakeholders, especially those who are active at sub-‐national level. This included training and information sessions on district health planning, health information systems, and monitoring and evaluation of National Health Development Plan activities. These training sessions led to a realization by both central and regional authorities that regional-‐level health sector reviews needed
“The process of reform and modernization of the administration in the public health sector in DRC is progressing in an irreversible manner with the participation of all and the support of our partners.” – The DRC Minister of Public Health, speaking at a National Steering Committee meeting supported by the UHC Partnership.
to be done more systematically – several were conducted in 2014 where they had never been conducted before. In Tunisia, following an extremely participatory health sector situation analysis, heavily supported by WHO, with input from focus groups, citizens’ juries, and Regional Health Forums, key strategic directions were discerned and elaborated upon in a one-‐of-‐a-‐kind livre blanc (White Paper) for a new National Health Policy for presentation to the government in the National Health Conference which took place in September 2014. The new health policy is expected to be finalized in 2015.
Expected Result 2. Countries will have put in place expertise, monitoring and evaluation systems and annual health sector reviews; In Burkina Faso, the UHC Partnership technically and financially supported the Annual Health Sector Review 2013 and a 6-‐Month Review, both of which took place in 2014; it was opened by the Minister of Health and with a strong presence of high-‐level MoH cadres, donor agencies, civil society, and others. The sector reviews have improved in their relevance and quality, not the least due to WHO support to the Thematic Commissions which discuss and prepare key technical topics beforehand. In addition, with WHO backing, the Secretary General of the MoH has taken a personal interest in improving health sector planning which has given an additional boost to the above-‐mentioned activities. In Togo, with WHO’s technical advice, a national-‐level database on district-‐level activities and their accompanying budgets took almost a year to put together as it contains detailed and verified information on District Operational Plans. This database is meant to aid the monitoring and evaluation of district-‐level health sector work and ensure that it is in line with the overall sector strategy. In South Sudan, the UHC Partnership technically supported and facilitated the development of a Monitoring and Evaluation Framework -‐-‐ not a feat to be underestimated in the difficult environment that prevailed during the course of 2014. This Framework will be implemented during the course of 2015.
Expected Result 3 Countries requesting health financing (HF) support will have modified their financing strategies and systems to move more rapidly towards universal coverage (UC), with a particular focus on the poor and vulnerable In Guinea, the National Health Financing Strategy Towards Universal Health Coverage was finalized with strong support from WHO, and the printed and disseminated copy is available. This strategy represents a fundamental shift for the Guinean health system as it specifically aims at generating sustainable funding to extend population access to a basic package of services (especially at primary healthcare level)—in contrary to the current situation where the population is burdened with high out-‐of-‐pocket (OOP) payments. Evidence unequivocally demonstrates that direct out-‐of-‐pocket payments are inequitable. In addition, the Ebola crisis in Guinea lays bare the fact that a health system with high OOPs is not resilient. Consequently, this essential aspect of the new National Health Financing Strategy (for instance regarding purchasing of primary health care) will be crucial
in designing the Guinean Health System Recovery Plan – a process which started in the last quarter of 2014 under the firm leadership of both the MoH and WHO. In Moldova, a study on out-‐of-‐pocket payments and inefficiencies in the health sector was conducted under the aegis of the UHC Partnership (see Results section). This study was quite comprehensive as it encompassed both formal and informal out-‐of-‐pocket payments (OOP) , a desk review of already published studies on the topic, an analysis of current legislation to assess what would be feasible when it comes to study recommendations, and an in-‐depth look at health expenditure data. The end product was a Framework for addressing OOP and informal payments for health services in the Republic of Moldova. The MOH with UHC Partnership support then organized a crucial policy dialogue session with key stakeholders to discuss the framework and a way forward. This initiative has helped keep this topic on the political agenda despite other election year priorities. As a result of the study, national authorities and principal decision-‐makers recognize high OOP payments and informal payments as priority bottlenecks to be addressed and the topic enjoys high visibility, as evinced by current awareness campaigns sponsored by the MoH. Expected Result 4 Countries receiving HF support will have implemented financing reforms to facilitated UC In Niger, a study on health intervention costs at different service delivery levels was conducted with WHO guidance as one important component of building a local evidence base for better design of universal health coverage. In Togo, health financing work was mostly focused on revenue generation for health. The study on innovative health financing, conducted under aegis of the UHC Partnership, was prepared during the first semester of 2014 and released in July. By proposing new tax mechanisms (plane ticket levy, mobile telecommunication taxes, alcohol tax etc.), exploring their institutional feasibility and simulating potential revenue, the study contributed to putting the question of increased fiscal space for health under the spotlight at an unprecedented level. The presidential administration and the Prime Minister’s Office were indeed actively present during debates together with the Ministry of Health and the Ministry of Finance, and this also created an opportunity to go beyond revenue generation and raise high-‐level awareness on the key concept of Universal Health Coverage and potential options for Togo. This created a favorable environment for the next steps on the health financing front: a situation analysis of the health financing system which started in Q4 2014, and will lead to the formulation of priorities for the health financing strategy towards UHC which will be developed in 2015. Expected Result 5 Accurate, up-‐to-‐date evidence on what works and what does not work regarding health financing reforms for universal coverage is available and shared across countries. This work serves to help countries inform and develop their health financing strategy/reform plans with the aim of accelerating progress towards UHC. At a global level, one focus was on how to improve health system/health financing efficiency. 11 country studies were undertaken which focused on health system reforms involving medicines, health insurance market, provider payment, human resources, and alignment of international assistance for health. The case studies illustrated that a concern with improving efficiency in the health sector is an important policy element in all
countries with different income levels. At the same time, improving efficiency is a challenging issue because it involves various players who benefit from the existing distribution and use of resources. Health system components are also complex and interrelated and therefore efficiency related reforms require a comprehensive systemic approach. In collaboration with other partners, WHO co-‐ organized a conference in December 2014 to discuss all country case studies, major findings and lessons learned. In the first half of 2015, WHO will produce a global synthesis report based on these case studies to improve and share knowledge and evidence on improving health system efficiencies in low and middle income countries. Another global work stream on evidence gathering related to government subsidization and government budget transfers to health insurance type schemes to cover vulnerable and poor population groups. This is now a widespread approach across the globe in more than 40 low-‐ and middle-‐income countries. The synthesized evidence shows that subsidization helped to increase enrolment and population coverage of poor and vulnerable population groups. Access to health services improved for these population groups, whereas financial risk protection improvements are more mixed. One of the important policy lessons to be drawn here is that UHC extension is contingent upon the careful design and effective implementation of critical institutional design features – exactly the type of support the UHC Partnership offers its target countries. Several countries are in the process of exploring or setting up such a financing arrangement, especially in Africa (Benin, Burkina Faso, Mali, Kenya, South Africa, just to mention a few) and can benefit from the findings and lessons learnt of this global review, which is being published and disseminated in various health financing policy events and trainings. These examples underline the fact that UHC Partnership results extend well beyond the Partnership countries only. The country exchange that WHO provides through its normative work as well as its regional and global platforms allows UHC Partnership results to spread well beyond the 19 countries at hand. In Vietnam, a one-‐week training of national stakeholders (involving MoH, other government ministries and Viet Nam Social Security) was conducted with Japanese and Korean experts on price setting and provider payment methods as well as the design of the essential health service benefits package and the systems for managing these mechanisms/processes. WHO guided and facilitated this training, identifying international experts and connecting them with relevant government stakeholders for information sharing and exchange. In Togo, a participatory situation analysis of the health financing system supported by the Partnership helped identify key challenges to the health system for achievement of Universal Health Coverage. These challenges have formed the backbone of the reflection process on the Health Financing Strategy discussions. The WHO approach called "Organizational Assessment for Improving and Strengthening Health Financing" (OASIS) was applied for this analysis, and WHO technically supported a multisectoral working group on its use, and supervised the different phases of this review. The analysis was based on interviews with key players in the health system and a review of studies, reports, and legislative texts on health financing and social protection in Togo. The preparatory work of collecting data to describe the prevailing health financing architecture preceded the writing workshop where stakeholders completed and validated the situation analysis and jointly proposed different potential strategic directions. This work contributes to the existing compendium of OASIS analyses and will also help other countries inform their own health financing situation analysis work, both as to process as well as content.
UHC Partnership results and impact In the following pages, several examples of key results and impact the UHC Partnership has been able to achieve in the last 3 years of implementation are presented. Results are decisive and tangible and a preliminary impact can also be ascertained. In some cases, there is a plausible path from the results achieved so far to potential future impact which is depicted below2. Methodologically, in an effort to take a holistic approach to progress towards UHC, an attempt has been made to look at qualitative as well as quantitative results and impact3 Illustrations have been selected which are exemplary in the sense that they are not one-‐off, but results which have been experienced and noted over time, and which may have taken time to fully materialize4. For example, the policy dialogue consultation depicted for Moldova below is just one of several consultations where the result has been higher visibility and more attention to the topic covered, leading to a specific expected impact. Those types of results merit particular attention, i.e. the results which repeat themselves consistently over time. In addition, activities have been highlighted where there were numerous intermediary results to be demonstrated – even though only one of them per country is depicted in the below results chain examples, each of the highlighted activities have actually led to several other important results as well. The point here is that one UHC Partnership activity has indeed led to various consequences and policy reactions, each of which lead to different types of impact. An illustrative example is the Cape Verde image below: the extensive work undertaken on the National Health Accounts (NHA) with Partnership support has ultimately led to an expected significant increase of the government budget for health in 2015. The NHA effect of a heightened awareness of key stakeholders on resource allocation inequities and on-‐going measures to correct for that could just as well been featured. WHO’s focus on the results chain and tangible as well as plausible impact is on-‐going and has been given a considerable impetus by the UHC Partnership. WHO will continue this momentous area of work in the last year of Phase II of the Partnership in order to better discern the Partnership’s contribution to better health outcomes.
2 Gertler, P. J. et al. (2010). Impact Evaluation in Practice: Ancillary Material, The World Bank, Washington DC. 3 Garbarino, S., & Holland, J. (2009). Quantitative and qualitative methods in impact evaluation and measuring results. Governance and Social Development Resource Centre (GRDRC). Birmingham, UK. 4 Bouis, R. et al. (2012). The Short-‐term Effects of Structural Reforms: an Empirical Analysis, OECD Economics Department Working Papers, No. 684, OECD Publishing.
Overall achievements and lessons learned Some overarching key achievements and lessons learned from the Partnership’s 19 countries can be found below. The principal take-‐home messages following 3 years of Partnership experience in 7 countries and 2 years of experience in an additional 12 countries are summarized below, further illustrated with some (non-‐ exhaustive) country examples:
1. Improved cooperation and coordination has been consolidated through the UHC Partnership work in several countries, and even exploited to the benefit of the Ebola response in others. The task of assuring better coordination of health sector activities and more cooperation between stakeholders sounds like an easy task but in practice, it needs active leadership, a sound technical knowledge base, and time to build trust. The UHC Partnership, as part of its ER 1 and ER 2, has put a heavy accent over the past 3-‐4 years on this issue and it has borne fruit. As results chain examples from Cape Verde, Moldova, Togo, and Tunisia discernibly demonstrate, improved cooperation and coordination can have far-‐reaching consequences: more coherent joint work plans, improved alignment with sector strategies, and thus a more concerted effort in activity implementation on the ground – thereby contributing to health services which are more in line with the population’s needs which should lead to overall better health outcomes. In the Ebola-‐affected countries, improved coordination and stakeholder cooperation built up and consolidated by the Partnership mitigated the effects of fragmentation which often develops in a crisis situation with the sudden influx of a multitude of health sector actors. The momentum of functional coordination bodies and inter-‐stakeholder trust enabled more rapid local discussion, debate, and decisions on Ebola disease outbreak response activities. In addition, WHO leveraged its knowledge and experience with the 3 Ebola crisis countries through its Partnership health systems work by convening a high-‐level global meeting in Geneva in December 2014. This meeting brought together major donors, academic institutions, partners, and the 3 countries themselves to agree upon the establishment of health system recovery plans with WHO support.
2. The UHC Partnership has provided pointed and timely support for a clear health reform agenda in several countries Health sector reform was necessary in post-‐revolution Tunisia, where population dissatisfaction was running high and a palpable pressure to change the situation could not be ignored. WHO, under the UHC Partnership, has been the leading player supporting the MoH in clarifying concrete measures for health sector reform as expressed by the population. As attested to in the Tunisia country report, the UHC Partnership has been the decisive support and resource base for the dialogue societal work, as confirmed by many key stakeholders in country. In fact, it has been so successful that the government officially recommended other sectors to take on the same methodology. A dialogue sociétal programme has recently been launched in the education sector, attesting to a change in mentality and governance arrangements beyond health (http://directinfo.webmanagercenter.com/2015/01/29/tunisie-‐lancement-‐officiel-‐du-‐dialogue-‐societal-‐sur-‐leducation/).
In Timor-‐Leste, The Partnership since its inception has supported the MoH in its reform priorities by focusing on a coherent set of sub-‐sector and programme strategies which are aligned to the National Health Sector Strategic Plan 2011-‐2030. This includes the National Strategy for the Prevention and Control of Non-‐communicable Diseases (NCDs), Injuries, Disabilities and Care of the Elderly and the NCD National Action Plan 2014 – 2018; the Reproductive Maternal Neo-‐Natal Child Adolescent Health (RMNCAH) Strategy2014-‐2018; the National Strategic Plan for School Health (2014-‐2018); National Blood Policy and National Blood Program Strategic Plan 2015-‐2019; National Laboratory Strategic Plan (2015-‐2019); E-‐Health Strategy (2014-‐2019);Short-‐term 3-‐year Action Plan for Cancer Control in Timor-‐Leste (2015-‐2017). The UHC Partnership was the leading player in developing Health Planning and Budgeting Guidelines which will reflect the overall NHSSP reform objective to ensure a central Ministry of Health role as a policy maker and regulator of the health system, with the district taking on the implementation role of planning, supervising, coordination and monitoring and evaluation of services in response to national priorities and community needs.
3. Gains and synergies with overall WHO core policy and planning work have been leveraged through the UHC Partnership WHO’s core areas of work in policy and planning often receive little attention and funding. The UHC Partnership has helped enhance WHO’s role in these areas and provided unequivocal synergies with its technical support to MoH in tasks which needed to happen anyway but were being neglected for want of dedicated staff and resources. By consequence, MoH’s policy and planning work has received a boost in priority through the UHC Partnership’s seed funding and has been anchored into joint work plans with stakeholders in countries such as Moldova, Senegal, Togo, Liberia, and Timor-‐Leste.
4. In fragile and crisis settings, the UHC Partnership has been instrumental in convening the dialogue between long-‐term development concerns and immediate humanitarian aid Many of the UHC Partnership countries are currently experiencing an emergency or crisis situation or are in a protracted conflict state. This environment admittedly makes harmonization and alignment of activities more cumbersome due to the need for more immediate and urgent humanitarian action for which coordination and cooperation may be seen as cause for delay. An obvious tension often crops up in such settings between the more urgent, short-‐term humanitarian needs and longer-‐term development concerns. WHO through the UHC Partnership has effectively used its policy dialogue work to convene both humanitarian and development-‐focused stakeholder groups to relieve this tension and agree upon short-‐, medium-‐, and longer-‐term objectives and activities – a case in point are the Ebola-‐affected countries and the current ongoing work on health systems resilience to avoid future such catastrophes. Another challenge in conflict and post-‐conflict phases is the fact that Ministries of Health are usually overwhelmed with already low capacity. Initiatives easily proliferate without coherent coordination and information sharing simply because MoH stewardship is lacking. The Partnership has played a key role in backing the MoH in demonstrating credible leadership in countries such as South Sudan to avoid health sector fragmentation.
5. In many countries, more alignment can be seen between annual operational plans, sub-‐sector
plans, and/or disease-‐specific plans on the one hand and the overarching national health sector strategic plan on the other hand From Chad, Liberia, Niger, and Guinea to Burkina Faso, Togo, and Timor-‐Leste, there is tangible evidence that annual operational plans or sub-‐sector plans, and/or disease-‐specific plans are more in line – and vice versa – with national sector plans. This is a major gain not to be underestimated because it directly affects the way health sector activities will be implemented at district level – the level at which the Partnership desires to make an impact on improving health services for the population in order to attain better health outcomes. In Timor-‐Leste, for example, as described in Overall Achievement and Lesson Learned #2, a major effort was made to ensure harmonization and alignment of a series of sub-‐sector and programme plans with the overarching National Health Sector Strategic Plan 2011-‐2030 to better support coherent implementation of health sector reform at a decentralized level.
6. Universal Health Coverage as a concept as well its practical implications in national health and health financing strategies is better understood in countries supported by the Partnership. This can be seen in a better articulated vision of UHC in many policy documents. The explicit emphasis on universal health coverage as a vision and aspirational goal for the health sector which WHO has brought with this Partnership has strongly influenced its technical support to Partnership countries. In countries such as Tunisia, Moldova, Cape Verde, and Togo, a more explicit and better understood vision of universal health coverage in its national policy documents and/or health sector reform perspective is perceived as a major achievement by local and international stakeholders alike.
7. Policy dialogue and national health planning does not happen by itself and needs dedicated staff to nurture it and follow up on it A brief glance at the country reports demonstrate that the above is the case in all country settings, be it Moldova or DRC. The MoH is often overstretched or its capacity is low in many countries so targeted support is absolutely needed in this area which is so rarely focused on by donors. By strengthening WHO Country Office with requisite policy and planning capacity, the UHC Partnership is allowing WHO to more effectively fulfill its core role of convening and brokering different stakeholders around key health sector issues.
8. UHC Partnership seed funding has aided in attracting more substantial funding for important health sector activities in many countries
“This is the first time in Liberia that the national level operational plans are based on such a bottom-‐up approach, whereby counties are directly influencing the national health strategy.”– Benedict Harris, Assistant Minister of Policy and Planning, Liberia
In Tunisia, for example, WHO’s technical work done on accreditation within the remit of the UHC Partnership provided much-‐needed synergies with EU Delegation (EUD) project support and led to much larger sums committed by the EUD for this area. In Togo, the Partnership has leveraged complementarity with other funding sources, such as the Muskoka funds, for critical Road Map activities. In Chad, a major coordination effort led to the Global Fund Health Systems Strengthening window work plan, with its accompanying generous budget, being completely aligned with the UHC Partnership Road Map and of course, the overall National Health Plan. Finally, we cite Senegal where synergies have been created between the UHC Partnership and USAID’s funding sources for health financing activities.
9. The UHC Partnership has helped build a stronger country-‐specific and global evidence base on what works well and less well with respect to moving towards UHC. In countries, the former has helped shape health financing reform priorities; at a global level, this helped to bring together lessons learned which were shared with countries to contribute to their health financing policy reflection processes. In Tunisia, Guinea, Sudan, Chad and Togo, up-‐to-‐date health financing system assessments have been conducted with support from WHO experts. In Chad, DRC, Guinea, Liberia, Mozambique, Timor-‐Leste, Togo, and Tunisia, National Health Accounts were updated which led to a better insight into expenditure flows. In Togo, a study on innovative means to raise new domestic revenues for health was completed and discussed in a workshop setting. Catastrophic expenditure analysis in Tunisia and Mozambique helped pave the way to formulate concrete policy options for improved financial risk protection of its citizens. These activities and many others helped WHO HQ bring together global lessons learned.
10. The UHC Partnership facilitated health financing policy discussions that led to a better integration of free healthcare policies within the overall health financing strategy. Several West and Central African countries have introduced free health care policies. Policy discussions facilitated by the UHC Partnership in Mali, Chad and Burkina Faso, for instance, have contributed to a better integration of these free healthcare policies within the overall health financing strategy. This not only increases overall system efficiency by reducing administrative fragmentation, but above all enhances equity in access to needed health services, especially of poor and vulnerable population groups.
11. The UHC Partnership has further consolidated capacity strengthening for evidence generation, analysis and interpretation by national policy stakeholders in the field of health financing. Evidence is crucial to building a solid foundation for the development of National Health Financing Strategies but they are also an important contribution to country UHC monitoring. Monitoring helps countries assess where they stand and how far they are away from their interim and final goals of UHC progress. An exemplary case is Togo, where a working group composed of members of the MoH, MoF, the national health insurance fund, and others, was trained and familiarized with advanced health financing notions and concepts of UHC in order to assist in the development of the innovative health financing study and later conduct the health financing situation analysis.
12. The UHC Partnership has supported the practical implementation of IHP+ commitments in several countries Most of the Partnership countries are IHP+ signatories: Burkina Faso, Cape Verde, Chad, DRC, Guinea, Mali, Mozambique, Niger, Senegal, Sierra Leone, Sudan, Togo, and Vietnam. The aid effectiveness component of the Partnership is clearly an integral part of the health policy& planning and health financing activities. More details are available in the IHP+ yearly report.
Principal challenges
1. The Ebola crisis in West Africa and in general, emergency situations in target countries As previously mentioned in the Year 2 Report, the volatile security situation in countries such as Yemen or South Sudan severely hampered long-‐term health sector development and policy dialogue work. Nevertheless, gains were definitely made as noted throughout this chapter as well as the country reports. The Ebola crisis escalated in the second half of 2014 and brought almost all Partnership activities to a halt, principally in the 3 directly affected countries of Guinea, Sierra Leone, and Liberia. Nevertheless, activities were partly re-‐programmed to respond to this dire situation and Partnership-‐supported coordination mechanisms were capitalized on for a more coordinated response to Ebola. Globally, the Partnership is actively involved in ongoing work on health systems resilience in not only the 3 key countries but also surrounding at-‐risk countries. To be noted here is that thanks to the UHC partnership and the in-‐depth knowledge of the health system situation in the 3 Ebola affected countries, the WHO HQ and AFRO teams supporting the UHC partnership, in close collaboration with the Partnership-‐supported international Health Systems Advisors, organized a “High level meeting on building resilient systems for health in Ebola-‐affected countries" in December 2014 in Geneva, Switzerland (http://www.who.int/healthsystems/ebola/en/). The meeting conclusions called on national governments to lead the work on building health system resilience, especially given that all of the Ebola-‐affected countries have national health plans which can be used as the basis for forward planning in light of the Ebola crisis. The principles and recommendations coming out of the December 2014 meeting will guide the reprogramming of the UHC partnership activities in the 3 countries.
“We signed the national compact in February after a year-‐long process during which we went through meetings in the different islands (we are a country of islands). It was very stimulating because we were able to get together associations, the private sector, pharmaceutical enterprises and institutions like churches, and municipalities… Not only did we sign the compact trying to consolidate and make our partnerships on health financing more effective, but also internally we built a coalition for bettering the prevention of disease and the promotion of health.” – Dr. Cristina Fontes Lima, Minister of Health of Cape Verde, on work which was supported by the UHC Partnership under IHP+.
2. Three years’ experience with this Partnership has demonstrated that several months’ lead time is needed to put in place a system, with adequate staff and resource flow, which allows for good levels of spending We see now that by the 2nd year of the Partnership, activity implementation and levels of spending jump noticeably once a few months’ time have been wisely invested in putting in place the right mechanisms and structures to implement correctly. This can be seen as a challenge when the duration of this Partnership is fairly short – 3 to 4 years; an even shorter effective time frame due to the initial lead time means that very little time is left for actual activity implementation.
3. Attribution of Partnership-‐led activities to overall results and health outcomes As mentioned in other sections of this report, policy dialogue and national health planning are cross-‐cutting, overarching issues which affect different areas of the health system in different ways. In principle, policy dialogue and planning processes provide an enabling environment for a health system to function in the most effective way. Attribution of Partnership-‐led activities which are focused on enabling per se to direct health outcomes is difficult and in some cases, not possible. Hence, demonstrating results and impact which can be traced back to Partnership activities is clearly a challenge of this work. Nevertheless, WHO has taken this challenge head-‐on and provided straightforward insight into the chain of events and reactions taking place following the implementation of its activities (see Results section). WHO will continue this work into 2015, together with academic partners and Country Offices, and provide further examples to discern the impact of this necessary and meaningful area of work.
Conclusion and Way Forward The third year of the Partnership, which included the second year of implementation for 12 out of the 19 countries, has shown that technical and financial support for health policy dialogue, health planning,
and health financing continues to be in great demand in countries as stable and middle-‐income as Moldova and Vietnam as well as in protracted conflict and fragile situations such as South Sudan, Guinea, Chad, Mali, and DRC. We risk repeating ourselves when we state perhaps the obvious: policy dialogue and constructive cooperation and coordination can happen slowly but surely if there is dedicated staff and resources to this area of work.
The UHC Partnership has directly enabled WHO to take a lead role in the convening, brokering, and fostering of dialogue which involves building trust and confidence as well as providing the necessary sector expertise and guidance to funding partners ; this is already demonstrating advantages which should continue on into 2015 and the longer-‐term. The Partnership has also made great strides in advancing Universal Health Coverage as a key concept underlying health financing strategies but also as a general goal towards which a health system should steer. Universal Health Coverage is not always an easy concept to grasp when it comes to its technical detail and practical implementation; this Partnership has allowed WHO to spend a considerable amount of time and funds in the target countries to clarify this complex concept, build crucial capacity with
“This is the first time we’ve involved so many stakeholders and held so many important discussions in the process of developing a national health plan.” – Mr. Moussa Issaye, Director Department of Planning, Ministry of Health, Chad.
decision-‐makers, and ensure better alignment of a country’s health sector goals with the aspiration of universal health coverage. Some of the work done under the UHC Partnership has contributed to a shift in thinking and gained such widespread admiration and acceptance that it is being replicated in other sectors – the case in point here is Tunisia and the dialogue societal which is slowly becoming ingrained in health sector decision-‐making. The Tunisian government has explicitly requested sectors such as education and transport to mirror the same approach to better formulate strategic directions supported by the population. The visibility of WHO, and its partners EU and Luxembourg, has continued to grow, also as a direct result of WHO’s targeted communication efforts and strategies. The visibility sections of the Country Reports confirm this, as do the local media clippings found in the annex of this report. International media attention for the UHC partnership has also increased in 2014 (see http://www.uhcpartnership.net/ joining-‐forces-‐4-‐prescriptions-‐for-‐healthy-‐partnerships/ and http://www.uhcpartnership.net/where-‐theres-‐a-‐will-‐there-‐are-‐many-‐ways-‐healthy-‐systems-‐and-‐disease-‐tailored-‐interventions/). In addition, the UHC Partnership web site – www.uhcpartnership.net – is visited on average by 300 people per day and has enjoyed over 5000 page views in the last four months alone. WHO will continue its global, regional, and country level Partnership activities into its last year of Phase II, with a planned in-‐depth evaluation towards the last quarter of 2015. WHO remains committed to overcoming the challenges mentioned in this and previous reports – in fact, many of them have already been solved and are no longer problem areas. In addition, gains already made will be solidified, with the aim of sustainability of the processes put in place. A particular emphasis in the coming months will be placed on studying key results and impact, in cooperation with partners and research institutions.