7
Sustaining and Increasing Long-Term
Investments in Health Systems

Jo Boufford from the New York Academy of Medicine opened the workshop session by noting that the issue of sustainability and long-term investments has come up throughout the workshop in discussions on creating business plans and market models that can succeed and be sustained. This session built on those discussions and the panelists highlighted intentional opportunities and mechanisms for sustainable public–private partnerships (PPPs) with an emphasis on financing and governance.

SUSTAINABLE FINANCING FOR HEALTH SYSTEMS

Soji Adeyi from the World Bank began his remarks on sustainable financing for health systems by first describing what he sees as the biggest drivers of trends in health markets.

Drivers of Health Market Trends

1. Demographic shifts based on population growth and change in the composition of populations. The global population is predicted to increase fairly rapidly over the next 30 years and, within that increase, the proportion of the elderly—a subpopulation that consumes a larger portion of health care—will increase.

2. Growth of economies. As income per capita increases, total health expenditure per capita also increases. As countries move from low-income status to lower-middle-income to upper-middle-income status, a significant portion of the increase in health expenditure is within the private sector and within that portion, a significant amount private, out-of-pocket expenditure at the point of service delivery.
3. Anticipated expansion and improvement in health care infrastructure in emerging markets.
4. Push for universal health coverage. The achievement of universal coverage, which is included in the Sustainable Development Goals (SDGs), will be a priority target for countries and will emphasize effective coverage and protection from poverty due to catastrophic cost of care.
5. Trade-offs between equity and efficiency goals.
6. Government and market failures.

Opportunities for Public–Private Synergies

After describing the major drivers within health markets that will affect the efficiencies and sustainability of health systems, Adeyi suggested several opportunities for synergies between the public and private sectors to increase the sustainability of health systems.

1. Including the private sector in service delivery under an umbrella that is publicly managed or publicly convened. Adeyi commented that Turkey’s health transformation model, which is mixing public and private sector resources toward the obtainment of universal coverage, is a promising example.
2. Addressing failures in pharmaceutical supply chains. This could include a switch to the private sector contracted by the public sector, or even quasi-public entities that are less beholden to the current system.
3. Improving the use of appropriate medical technology and equipment. Adeyi noted that recent reports have shown that in African countries roughly 40 percent to 70 percent of medical equipment lies idle. There is a need not only for equipment, but for training and services performed with the equipment.
4. Involving the private sector in human resources for health. A labor-market approach to analyzing the demand and the supply within human resources, compared with the populations, could more effectively identify imbalances and opportunities.

5. Interfacing between financing of health systems and disease control.

In considering these opportunities, Adeyi shared some current promising approaches for sustainable financing of health systems through a mix of the public and private sectors. Using a working definition of sustainability as the “attributes through which a program can continue to be adequately financed from a combination of domestic and global sources with a progressive shift toward domestic financing,” Adeyi suggested the necessary elements of a sustainable program are financing on budget, with the host country contributing the first funding; providing demonstrable value; and explicit agreement among the partners to progressively increase the use of domestic resources. If these three conditions are not there, Adeyi feels the prospects for medium- to long-term sustainability are bleak.

In the recent past and to some extent currently, Adeyi noted that some large programs are almost purely bilaterally financed by external agencies and they have not been sustainable because there is no ownership as they face a steep cliff as external financing dries up. Adeyi added that several countries have attempted sector-wide approaches with the promise of harmonization and reduction in transaction costs. These approaches, however, have some drawbacks because they are somewhat weak in terms of explicit results for cost—in that, a heavy emphasis on process and a relative weakness in outcomes.

Adeyi shared that recently there was a move on the part of the World Bank toward the Program for Results, which is explicitly anchored on measurable results and crowds in funds from all sources. The idea is to unify the promise of being on budget, the promise of being system-wide, and the promise of being results-focused.

A recent example is the new global financing facility in support of Every Woman, Every Child, which Adeyi shared as an example of attempts by multiple partners, including the World Bank, to address the large disparities in maternal and child health while fostering new ways of financing for development in the post-2015 era. The promise of this initiative includes a focus on achieving and measuring results, large scale use of country systems, and emphasis on transitional financing as a route to sustainability. A final example discussed by Adeyi was the Affordable Medicines Facility-malaria (AMFm). The intent of AMFm was to bring together the public and private sectors to increase access to antimalarial medications, using a new architecture to finance development assistance. The partnership succeeded in cutting the price of antimalarials at the point of consumption and increasing availability, even in remote regions. However, AMFm has not been sustained; this illustrates, from Adeyi’s

perspective, the limit of the appetite of the global health financing community for evidence that is not politically convenient. An independent evaluation provided strong evidence of the success of the AMFm, but the political will to back it was lacking.

THE ROLE OF THE PUBLIC SECTOR IN SUSTAINING PARTNERSHIPS FOR HEALTH SYSTEMS STRENGTHENING

Jeffrey Sturchio from Rabin Martin discussed the role of the public sector in ensuring health systems partnerships are mobilized and sustained. Current estimates indicate the health sector makes up about 10 percent of global gross domestic product (GDP), Sturchio explained. He suggested that, as the global community focuses on the transition to universal health coverage, it will be important to mobilize all stakeholders who are involved in that health economy. Businesses provide employment and run programs across the economy—everything from developing new medicines, vaccines, diagnostics and medical devices, to health care delivery and pharmacy care to health insurance. By contributing to the health economy, businesses across all industry sectors are also helping to contribute to health outcomes. Sturchio suggested that this contribution tends to be overlooked in discussions about universal health coverage and health systems strengthening. As government policies are developed for achieving universal health coverage, Sturchio argued that there has not been enough attention focused on how to stimulate partnerships to ensure the most efficient use of all the resources available. To sustain long-term private-sector investments in universal coverage and health systems, Sturchio named three areas where governments should focus: mobilizing and utilizing market forces in a constructive way, identifying gaps in the system and ways that partnerships can help to bridge them, and being more open to and engaged in reaching out to the private sector. He also suggested several ways in which governments can change the way they operate to help provide for more partnerships to achieve scale for universal health coverage:

• Have a clear policy to work with the private sector to encourage dialogue and partnerships.
• Make sure there is accurate information about the scale and scope of private health care resources in the country.
• Use regulation, registration, and other public sector tools as creative ways to support partnerships with the private sector.
• Think more about incentives, financing support, and other ways to encourage the private sector to become involved in public provision in a way that expands the envelope for health care coverage.

SCALING UP AND SUSTAINING PARTNERSHIPS FOR HUMAN RESOURCES FOR HEALTH

Noting the importance of addressing human resources for health as part of health systems strengthening, Mushtaque Chowdhury from BRAC presented a partnership to promote community health workers that has proven to be scalable and sustainable. Community health workers have been integral to the BRAC model for more than 40 years. After the Alma Alta Conference in 1978, where the role of community health workers was discussed, there were numerous experiments to train community health workers and, unfortunately, most of them failed in many parts of the world. BRAC started training community health workers in the late 1970s, and now has about 105,000 of them working alone in Bangladesh and another 30,000 working in other countries.

What are the partnerships within BRAC’s community health worker model? The partnerships exist at several levels: the village-based community partnerships that select one of their members to be a community health worker; the pharmaceutical company partnerships through which pharmaceutical companies provide medications to community health workers to sell; and the partnerships with the government health system. There have been extensive studies in Bangladesh and elsewhere to assess the effectiveness of community health workers, and BRAC has seen that these workers are able to provide treatment for all kinds of diseases, including complex diseases such as tuberculosis (TB). Additional evidence demonstrates a significant level of community satisfaction with the role of community health workers. Recently, a randomized controlled trial was conducted in Uganda using the BRAC model to assess the impact of community health workers on child mortality. The findings showed up to a 25 percent reduction in child mortality resulting from the community health worker model.

While the evidence base for the effectiveness of the BRAC community health worker model is growing, Chowdhury acknowledged that many community health worker models have failed. He suggested two issues leading to these failures. One is that community health workers are often trained and then left on their own, with no connection to the health system. The second issue is the lack of incentive for the health workers. In most cases, community health workers are women from poor families who are working without any incentive. BRAC’s model includes incentives in the form of micro-credit, financial benefits from selling medications (in countries where it is allowed). Additionally, in places where they are working on a particular program (such as TB) that is funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, community health workers receive a financial incentive after identifying a TB patient and providing DOTS (directly observed treatment, short course) treatment.

Through these mechanisms, BRAC’s community health worker model has been sustainable and scaled up within and across countries.

In response to a question about the issue of regulatory frameworks and licensure for the community health workers, Chowdhury commented that it varies from country to country. In Bangladesh, for example, regulatory issues exist. Nevertheless, 95 percent of the health workforce is in the private sector and the informal sector. Although by law “village doctors” are not allowed to practice, BRAC knows they are all over South Asia; so it is not enforced. BRAC is facing problems in some countries, Chowdhury noted. For example, in Sierra Leone, the government does not allow community health workers to sell medications without a license, and the sale of such medications is an important incentive of the community health worker model in most countries. It varies from country to country depending on what the regulations are and how these regulations are enforced, and requires specific understanding and development based on the local context.

COMMUNITY OWNERSHIP AS A MODEL FOR SUSTAINABILITY

Rajesh Anandan from the U.S. Fund for UNICEF addressed the trade-off between equity and efficiency and suggested that there does not always need to be a trade-off between the two, particularly when ownership is given to the consumers. The funding available for health systems strengthening is not expected to increase significantly: foreign assistance budgets are not increasing, tax bases in the least-developed countries are not growing fast enough to meet demand, and private provision is not able to provide an equitable service for those at the base of the pyramid. Considering the limited resources available, many discussions are revolving around how to become more efficient with what is available. However, Anandan suggested that one of the most powerful tools would be to create community ownership.

In terms of country ownership, Anandan noted that the development community has shifted. Development aid is now seen as partnering with communities and serving the needs of the community, rather than being viewed as something done to communities. Anandan discussed a few development models that are based on the premise of community ownership as central to sustainability.

Cash Transfers

UNICEF is experimenting with cash transfers in a couple dozen countries as a way to give ownership at the household level for decision mak-

ing related to the health system. In Liberia, for example, UNICEF has seen cash being used for transport to health services. There is also great potential in countries such as Kenya, where two-thirds of the population of 45 million people have mobile phones and half of mobile subscribers have mobile cash. Suddenly, the ability of even the poorest citizen to have access to information, services, and money, changes dramatically.

Last year, the largest crowd-funding platform in the world was GoFundMe, which raised about $480 million. GoFundMe is direct peer-to-peer giving, and the most common cause that individuals and families were raising money for was emergency health care expenses. If the percentage of philanthropy that goes to international causes (about 5 percent to 6 percent) is applied to crowd-funding, it would total USD 5 billion of household-to-household giving in one decade.

There are other ways to finance. Anandan provided an example of a program in Rwanda and Kenya that is providing oxygen. For this program, UNICEF partners with General Electric (GE), Frog Design, and a few local nongovernmental organizations to build oxygen plants in both countries. The availability of reliable, cheap oxygen is not easy to come by and this dearth leads to many infant deaths. GE donated equipment that creates oxygen from the air, then UNICEF developed local ownership structures. Frog Design, a U.S. design agency with experience in emerging markets, wrote the business plan. The board included the Ministry of Health, the local host hospital that was the primary customer these businesses started serving, and a local team who were trained to run the business. The first obstacle identified was the lack of demand. Consequently, the program pivoted and started training health care workers and administrators on why oxygen was beneficial, which, in turn, created the demand. Thereafter, the program moved quickly, and now the businesses are close to being self-sustaining.

Another innovative example Anandan described is You Report, which is currently running in about 12 countries. A simple idea, You Report is a way for young people to communicate their needs and the needs of their communities and to get information in real time. UNICEF identified almost 1 million “You Reporters” under the age of 30 across 12 African countries. The initiative is scaling quickly: an estimated 5 million You Reporters will be engaged by the end of 2017. When UNICEF sends a question to the You Reporters, it is receiving a 30 percent response rate. Think about that, Anandan stressed. In Uganda, a question went out asking You Reporters about corporal punishment in the school system—99 percent said they did not agree with it. Within 2 weeks, Parliament passed legislation that banned corporal punishment around the country. Through You Report, they have started getting unsolicited messages that actually

required a real response, such as “I have HIV” or “My clinic ran out of drugs.” The cost of having the monitoring and evaluation resources to gather this information would be prohibitive, but the impact of having a couple hundred thousand You Reporters in Uganda spread out geographically and not biased by income was priceless.