THE KAMPALA SYMPOSIUM STATEMENT ON HEALTH FINANCING FOR UNIVERSAL HEALTH COVERAGE IN LOW AND MIDDLE INCOME COUNTRIES
THE SERENA HOTEL, KAMPALA, AUGUST 16-18, 2017
Globally, the focus in the health sector has shifted towards the goal of achieving Universal Health Coverage (UHC). This goal entails ensuring healthy lives and promoting well-being for all at all ages” (goal 3.8) as part of the Sustainable Development Goals. Subsequently, countries are grappling with strategies that could optimally support progress toward UHC. With the recognition that previous global health initiatives have persistently not benefited the most vulnerable populations, one key strategy for achieving UHC has been identifying those health financing reforms which will make health more accessible, affordable and equitable for all.
From the 16-18 August 2017, Makerere University School of Public Health – Supporting Policy Engagement for Evidence-Based Decision Making (SPEED) for UHC in Uganda program in collaboration with the Ministry of Health, Uganda, hosted an International Symposium on Health Financing for Universal Health Coverage in Low and Middle Income Countries. The symposium theme was “Financing for Universal Health Coverage: More money for health AND more health for the money”. The overall aim of the symposium was to critically examine the existing health financing systems and policies for advancing UHC and systems development in Uganda and other low and middle-income countries so as to inform strategies that are geared at achieving UHC in the region. Symposium participants included members of the research community, policy makers, practitioners, civil society, NGOs and students. Delegates came from Ghana, Senegal, Rwanda, Nigeria, Democratic Republic of Congo, USA, UK, Switzerland, Belgium, India, Zambia, Mali and Uganda.
We the delegates made the following observations in line with the subthemes of the Symposium.
a) Ensuring financial risk protection using public funds
- Government financing for health is the most preferred source of funding given its capacity to provide health risk protection. However, public allocations have remained consistently below the bench-mark (15% of Government budgets across LMICs (current 6.1% for Uganda)
- Address inadequate investments in building and strengthening the health system, manifesting in workforce shortages (quantity and skills mix), high stock-out of medicines and equipment
- Local government that carry the mandate for service delivery have received low government budget allocations for health and other related programs – need to make optimal improvement in service coverage and quality.
- Current investments in the preventive and promotive health agenda remains sub-optimal, yet these have the potential to reduce the bulk of health system costs.
b) Risk sharing and pooling of funds through insurance
- Out of pocket payments still constitute a big proportion of health financing (40% in Uganda), which is inequitable (access and finance) and associated with catastrophic expenditures.
- Many Low-Middle income countries are currently implementing health insurance although at different stages of implementation. The Uganda NHIS Bill is currently under consideration.
- Existing prepayment schemes are faced with a number of challenges including fragmentation, low coverage (membership and breadth of benefit packages), and exclusion of the poor, and poor management, thus may not adequately address financial risk protection for the population in the short to medium term.
c) Leveraging health benefits from investments in other sectors
- Improving population health requires a multi-sectoral approach given the range of other determinants of health (SDH). Controlling population growth for instance is a strong lever for reducing health costs.
- A number of initiatives that benefit health are already happening in other sectors, e.g. Works, Roads and Transport, Agriculture, Water and Sanitation, Environment and Social Protection.
- Low-middle income countries are grappling with operationalization of the multi-sectoral approach to health improvement. Limited understanding of the concept, weak coordination and collaboration mechanisms, and preference for working in sector silos.
d) Strategic purchasing and results benefits package
- Traditional provider payment systems that are input-based tend to escalate geographical inequalities, do not fully reflect population health needs, and do not give incentives for coverage, quality and efficiency.
- Experiences with Performance-Based Financing (PBF) were noted to advance provider accountability, and improve service coverage for selected services. However, operational research on a number of challenges is required;
- Successful implementation of RBF requires appropriate institutions and a functioning health system
- Non-state actors (Private for profit and private not-for profit) compliment the public sector in health service delivery, and thus can help improve population and service coverage in LMICs. However the cost of service provision in these sectors remain unknown.
e) Global health initiatives and innovative financing
- Low-middle income countries heavily rely on development partner funding including global health initiatives. This however has challenges including poor alignment with national priorities, unpredictability, sustainability, and lack of national ownership.
- Adoption of expensive new technologies including medicines, diagnostic technologies and new vaccines, often supported by external resources are driving health care costs in a manner that slows down the financing capacity for greater coverage goals.
- Community innovative financing strategies exist e.g. crowd funding, local financial social networks, which may be leveraged to mobilize additional resources for health.
From the three-day deliberations, we symposium delegates propose that:
- Countries develop a clearly defined roadmap for achieving Universal Health Coverage that is appropriately benchmarked and contextually adapted. This roadmap should invariably have a clearly defined Monitoring and evaluation framework to monitor progress as well as feedback for better implementation.
- Countries identify and adopt strategic mechanisms to address the key drivers of high costs of health care provision and access including strategies to manage growing populations, regulate new and expensive health technologies, improve health system efficiencies, and bolster adequate investments in preventive health.
ACTOR SPECIFIC CALLS FOR ACTION
- Progressively increase government budget allocations for health as the major health “insurance” mechanism for Uganda that will guarantee fair access to health care services for all.
- Develop a roadmap for implementation of a NHIS that will increase coverage (services and population) and financial protection especially for the poor and vulnerable also known as “progressive universalism. Among other actions, this requires financial allocation to local governments to triple in size from the current provisions.
- Invest in the health system and its governance institutions, as a cornerstone to sustaining interventions aimed at achieving Universal Health Coverage, including; regulatory, training, procurement, information management and local governments institutions to optimize value from available financial allocations for health improvements.
- Mainstream health and wellbeing improvements in all policies and agenda of Government using the Health in All Policies (HiAP) approach – especially by leverage investments and coordinating collaborations to optimize the contributions to health and wellbeing outcomes from all sectors of society.
- Incorporate a learning agenda in the RBF design and implementation as a prelude to social health insurance scale-up.
- Emphasize and support stakeholder engagements in all UHC discussions, policy and decision making processes and implementation to ensure ownership, responsibility, and accountability
Civil society and Media
- Work closely with government, communities, and other stakeholders to engage in advocacy for increased government budget allocation for health programs – especially preventive programs.
- Create platforms for improved awareness for improving healthy behaviors, self-help community programs including saving schemes and crowd financing to finance health, governance and accountability in health spending and service delivery.
- Monitor and Identify service coverage gaps and provide effective advocacy and institute remedial programs for vulnerable communities.
- Mobilize and harness community resources and existing community support systems and networks to advance the Universal Health Coverage agenda.
- Health Development Partners (HDPs) should recommit to adhering to the principles of the Paris Declaration on AID effectiveness. In the short to medium term, improve the financial support for health programs – including the aid amount, predictability and the use of national financial systems so as to improve planning for aid programs and boost accountability and oversight of aid programs by legitimate national institutions.
- Invest in strengthening the capacity of the health system to expand coverage and use health funds effectively – including increasing the production and skill mix of the health workforce.
- Progressively broaden the decision space by government to allocate aid to the most pressing health needs in the country including investments in programs for health systems strengthening and health prevention and promotion.
- Progressively enter compacts with government that clarify the transition plans for aid programs to sustainable programming approaches that get to scale.
- In the short-term HDPs should consider allocating a proportion of their development assistance for health to be pooled in a trust fund for supporting national health insurance scheme particularly to cater for the most vulnerable populations.
Academia and research institutions
- Undertake operational and implementation research that is geared to supporting government and other stakeholders in reducing the illness burden and optimizing health benefits from available and additional financial resources for health.
- Support the costing and cost-effectiveness of health programs and innovations that support the effective stewardship of collaboration across sectors. This is vital to support the realization of the multi-sectoral contributions to the health and wellbeing programs across government, in the non-state sectors and communities.
- Create spaces for engagement and debate and sharing of evidence and experiences for policy and implementation issues relevant to Universal Health coverage.