The global movement toward universal health coverage has led countries to take a fresh look at how they finance their health systems, and how international partners support them. For the past two decades, the global community has focused mainly on debating and promoting specific health financing instruments—from user fees to close government health revenue gaps, to earmarked payroll taxes for social health insurance in low- and middle-income countries, to results-based financing, and so on. This focus on technical solutions has been a very comfortable place for technical experts who, too often, drive the agenda.
Not surprisingly, we have discovered that these narrow instruments are not magic bullets. And when chosen for technocratic reasons or designed in isolation, they can even do more harm than good, particularly when it comes to equity. More fundamentally, we have discovered that the focus on technical solutions will not drive progress in what is essentially a political journey.
While “politics” is not our business, to be more effective the global health community must move from simply promoting technical solutions toward something quite different. We must do better at supporting robust, inclusive country-led processes and investing in and facilitating capacity-building for institutions and individuals. We also need to pay more attention to strengthening strategic communications and stakeholder engagement, as well as creating more opportunities for effective cross-country collaborative learning.
We believe three major shifts are needed for effective global support of a country-centered path to UHC:
The first shift – From projects to processes.
The traditional two-to-five-year donor-funded project takes a narrow view of health financing problems and solutions, and focuses on short-term results. This often creates perverse incentives to deliver measurable outputs rather than focusing on strengthening the foundations for sustainable gains in health financing policy, such as institutional development, capacity-building and process improvement. It also creates fragmented, project-specific agendas that may or (more often) may not align with the country’s policy priorities and political economy realities. This misalignment is ineffective at best, and at worst creates real distractions and misdirection for the country’s policymakers and other stakeholders.
New, more flexible and country-driven mechanisms of engagement by global partners can better support the inclusive processes necessary for consensus-building around health financing policy solutions, which often require tough trade-offs. These new mechanisms for engagement can also better support the context-specific institutional capacity-building that is needed to sustain these processes.
The second shift – From “fly-in/fly-out” technical assistance to building networks of regional and country expertise.
Traditional donor-funded projects often rely on a “fly-in/fly-out” model of providing “high-level” technical expertise a few weeks at a time. This kind of support is incompatible with what is needed to strengthen institutions and improve processes for sustainable change management. Short-term technical support also often struggles to gain legitimacy, because it lacks deep connection to the broader political and economic context of the country, and it underestimates the non-technical expertise necessary to navigate complex and politically-charged issues credibly and effectively.
Even when projects send longer-term advisors or embed them in a government institution, country partners rarely have influence over who is hired or how to ensure accountability for performance. Other times partners build a parallel in-country infrastructure that draws top talent away from local institutions. Some programs aim to build local capacity, but these often involve one-off trainings or other methods of unproven effectiveness. Experts who are drawn from contexts and experience closer to the reality of the country and are available to support a longer-term coaching relationship are more likely to provide support that is relatable and appropriate.
It is time to acknowledge that it is not only the locus of expertise that needs shifting, but also the nature of expertise. There are tremendous political economy challenges to health financing for UHC — it fundamentally changes who gets what and who pays for it, particularly as primary care becomes more central. Current engagement and dialogue processes are often limited to a small group, and fail to include key stakeholders — ranging from the ministry of finance to local government leaders to private sector players, researchers and civil society. It should come as no surprise that opposition often becomes entrenched.
Health financing policy interventions require technical knowledge, but other skills like communication, advocacy and facilitation are also critical for managing competing stakeholder interests, sharing knowledge and building consensus.
The third shift – From static knowledge creation to co-produced practical resources based on implementation experience.
The theoretical tenets of health financing for equitable progress toward UHC are widely known. There is also abundantly available research on the impacts of different health financing instruments. But progress on implementation remains sluggish. One reason is that the challenges many countries face are not about what to do, but rather how to do it — how to design context-appropriate policies that meet social, economic and political objectives; how to overcome implementation challenges and stakeholder opposition; how to adapt and build on knowledge and learnings from other contexts.
This third shift addresses the very nature of knowledge creation and management, moving from traditional reports and published papers (focused on “what to do”) to an emphasis on practical resources and tools built out of collaborative learning and co-produced with country partners based on implementation experience (focused on “how-to”).
Platforms such as the Joint Learning Network for UHC (JLN) and others are already helping countries share and synthesize their experience into co-produced practical tools, such as manuals and toolkits, that other countries can adapt and use. An additional step is needed to translate this co-produced knowledge so that it can be effectively incorporated into country processes.
Embracing these shifts: Two new initiatives
Results for Development (R4D) is fully committed to these shifts, beginning with two new initiatives. They are the African Collaborative for Health Financing Solutions (ACS), funded by the U.S. Agency for International Development, and the Strategic Purchasing Africa Resource Center (SPARC) funded by the Bill & Melinda Gates Foundation.
Through these two mechanisms, working collaboratively with USAID and the Bill & Melinda Gates Foundation across initiatives, R4D is building alliances and evidence for fundamental changes in the way we support countries to advance a country-led, primary-care-centered path to UHC, not only in sub-Saharan Africa, but in all of our partner countries.
Both ACS and SPARC seek to provide platforms for countries to address the deeper political economy and process management challenges that can stall implementation of health financing and governance interventions on the path toward UHC. ACS and SPARC share three fundamental dimensions to their approaches:
- Creating new models of flexible, country-driven support. ACS works with regional bodies and country-level, multi-stakeholder platforms to identify implementation barriers and knowledge gaps, and to strengthen country processes to address them collaboratively, to improve accountability and to advance UHC in sub-Saharan Africa. SPARC builds a “hub and spoke” model linking country stakeholders to a network of Africa-based experts and institutions with deep experience implementing strategic purchasing approaches to strengthen primary health care as the cornerstone of UHC. SPARC will co-develop and broker flexible, demand-driven packages of support for countries that want to make better use of limited funds through strategic health purchasing practices.
- Building and supporting a network of Africa-based expertise. ACS is drawing on Africa-based expertise in health financing and building capacity for process facilitation at the country and regional levels to provide neutral support – and to engage a range of stakeholders to strengthen their capacity to navigate political economy challenges. SPARC will use a coaching and mentoring approach to support a cadre of Africa-based experts (individuals and institutions) and provide a platform for them to build demand for their services and learn from each other. The aim is for this cadre of experts to become the go-to source of support for countries seeking to implement strategic purchasing practices. Through these approaches, ACS and SPARC will work together, and hopefully with others who share this vision, to build a robust, sustainable and autonomous African network of health financing expertise.
- Providing opportunities for collaborative learning that is focused on practical how-to’s and fostering robust, inclusive processes. Both ACS and SPARC will build on the experience and resources of the JLN and other such platforms in collaborative learning and knowledge co-production. ACS will build capacity and support for a structured, iterative learning process at the national and sub-regional level. The initiative will leverage existing networks, organizations and institutions to advocate for accountability in health financing, to share knowledge and provide direct support to advance country priorities. SPARC will work with institutions across the region that are engaged in strategic purchasing to collect and synthesize country implementation experience and translate it into accessible and practical resources to be made available through a database of knowledge products and tools.
These two initiatives, working collaboratively, aim to situate technical health financing solutions more firmly in the realities of country processes and politics, and to provide more holistic support to navigate these realities. The three shifts underpinning our approach will also require an evolution in how development partners define and measure the results of their support, a key issue we plan to explore in earnest. In 2018, we invite other global and regional partners to join in this movement to make the three shifts needed in order to accelerate progress for UHC at the country level.