Wyss, Kaspar

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    Swiss Centre for International Health  Post conference report  with special consideration of main messages coming out of the confer-ence and suggesting action options for GEH and RM with regard to the health financing   “Governance” – the interplay between health, equity and financing Saly 25 to 30 April 2005  April 2005 by Kaspar Wyss  Proj-comp number: 1022283-001   Table of contents  Abbreviations................................................................................................ 2 Summary...................................................................................................... 3 Background .................................................................................................. 4 General observations ................................................................................... 5 Main conference messages.......................................................................... 6 Options for GEH and RM with regard to the health financing theme............ 7   Abbreviations  ART  Anti-Retroviral Therapy COHRED Council for Health Research and Development GEH  Governance Equity and Health GFHR  Global Forum for Health Research IDRC  International Centre for Research Development PEPFAR Presidential Emergency Plan For AIDS Relief RM  Research Matters within Governance Equity and Health SDC  Swiss Agency for Development and Cooperation   2Summary  This post-conference report of the Governance Equity and Health (GEH) and Re-search Matters partners meeting in Saly, Senegal (25 to 30 April 2005), highlights main messages coming out of the conference and suggests to GEH and RM possible action to carry forward research in the area of health financing.   The central understanding of participants was the primary bottleneck to achieve the MDGs in low-income countries is health systems that are too fragile and fragmented to deliver the services to those in needs and that health research which takes into account governance and equity has an essential role to play. Main messages in-cluded: (1) The presence of different concepts on governance and sometimes vague understanding of how to address governance within health research; (2) Equity as a main concern which has to govern health action, but simultaneously a possible better harmonization between different dimensions of equity such as resource mobilisation, allocation and utilization; (3) The GEH initiative as a rich source for networking, ex-change and concerted action across different research groups, but also a need to better detail and make use of the added-value of the initiative as whole; (4) RM within GEH as an important opportunity for some researchers and research groups to un-derline their activities and to close the research to action loop.  Many opportunities exist for GEH to fund research in the broad area of health financ-ing and to establish bridges between research results and action (e.g. “Dar Es Sa-laam meeting” in May 2005 on health financing strategies). Opportunities in the area of health financing for GEH and RM include: GEH’s flexible and non-bureaucratic mechanisms for funding research, the responsiveness to emerging de-mands and need for evidence for decision-making, the proximity to decision-makers, as well as the joining of the concepts of Equity, Governance and Health.  At the current point of time GEH, should not restrict itself thematically and remain open to emerging research questions. However possible research entry points are:  (1) How the donor agenda and national priorities/ownership  interact? (2) Suc-cess as well as failure stories of recipient governments’ attempts to coordinate do-nors (and eventually the private sector) and pool re-sources specifically in the area of HIV/AIDS. (3) Evidence around the pooling of funds; (4) ART and rationing of service provision; (5) Evidence that ART may contribute to health systems strengthening, for example through the integration of ART services; and (6) Effects of PEPFAR and other Global Health Initiatives on health systems   3Background  In the framework of the Governance, Equity and Health programme (GEH) Initiative funded by the International Centre for Research Development (IDRC) and the Swiss Agency for Development and Cooperation (SDC), a conference was held between 25 and 30 April 2005 in Saly, Senegal. Within the broad ranging frame of strengthening research in GEH and in making research an engine for action, the conference aimed to: • Explore conceptual, methodological, and practical dimensions of governance and the complexities surrounding financing for health with consideration of equity and gender; • Stimulate discussion on the intersection of governance, health, equity, gender and financing; • Explore a research agenda that addresses all concepts: health, equity, gender and financing with respect to governance.  The conference was also intended to be a marketplace, providing the opportunity for group work and informal exchanges between researchers. Group work was organised around four topics: (1) Governance and Plural Health Systems; (2) Governance and Human Resources; (3) Corruption, system leakage and accountability and (4) power: Who are the decision makers? This with the idea to allow for the exchange of ideas, sharing of experiences, identification of challenges and development of strategies, interventions, research products etc that go beyond the specific interests of a single research team and through which the GEH community of practice can contribute to addressing broad research and development issues.  The following document intends to be a post-conference report which specifi-cally highlights main messages coming out of the conference, suggesting ac-tion options for GEH and RM with regard to the health financing theme.   Consequently, in a first section this short report describes general observations on the conference entitled “Governance” – the interplay between health, equity and fi-nancing. Then, the document summarises key messages resulting from the group and plenary discussions and summarises possible opportunities for GEH and RM in the area of financing health care in view of the “health financing” conference which was held in May 2005 in Dar es Salaam Tanzania. Indeed, this was of relevant for GEH and RM as the workshop aimed to share experiences, lessons and knowledge and to take stock among stakeholders on health financing options in Tanzania as well as to provide information and experience that will enable the GOT to begin to deter-mine the best for the way forward for financing the public, private for profit and private not for profit health sector in view of strengthening the national health financing strat-egy of the Government of Tanzania. Results and discussion are highly relevant to GEH and RM as they indicate the need for research for informed policy making while carry forward debates in the area of user fees and social health insurance.   4General observations  The conference was attended by more than 100 resources persons representing the research community from the Caucasus, India, Africa and Latin America funded through GEH and a range of persons and institutions such as IDRC, COHRED, GFHR and others. Most of the projects funded under GEH have started over the last one two years. Topics investigated are broad ranging from “Assessing the Impact of HIV/AIDS on Health Service Capacity at Primary Care Level” in South Africa to “Pub-lic policies against social exclusion” in West Africa and additional information can be found at http://web.idrc.ca/en/ev-24613-201-1-DO_TOPIC.html.   The conference did achieve its aims and could most importantly: • Provide a platform for exchange between research and researchers es-pecially between anglo- and francophone Africa. As there are relatively few events of this kind which bring together not only health researchers  active in the area of governance and equity but also to associate them to decision-makers and research funders the conference could further deepen the con-ceptual and practical understanding of governance and equity;  • Be a bridge between the thinking, priorities and concerns of researchers working in different countries and contexts;  • Be a platform for debate and synthesise efforts in the field of governance, equity and health as well as research capacity strengthening while paying special attention to the needs of the strengthening (governmental) health sys-tems.  • Identify and debate critical and controversial issues around governance, equity and health and give special consideration to priority topics such as ac-cess of the poor and vulnerable to health services, health systems strengthen-ing and financing, etc.  Issues that might be strengthened within similar future events of GEH include: • More clearly defined conference objectives and better alignment be-tween group work and plenary sessions. Indeed, the value of the group work lies in feeding of results into the conference output and conclusions. In practical terms this might also imply to better inform and brief participants (presenters and facilitators) on conference objectives, format and expected outputs;  • Added-value of joining individual projects under an umbrella – the GEH initiative – and promoting their interaction in the context of a confer-ence. Indeed, an initiative offers the potential for being more than the sum of individual projects, through promoting common frameworks, analysis and comparison thereby creating an added-value. Consequently and based on experiences of individual projects, the GEH core group may promote the es-tablishment of joint frameworks and cross-project analysis and comparison;   • Utilisation of the conference for promoting joint agreements and decision on research and development priorities at the interface of governance, equity and health.    5Main conference messages  The central understanding of conference participants was the primary bottleneck to achieve the better health outputs in low-income countries consists in health systems that are too fragile and fragmented to deliver the volume and quality of services to those in needs. In this context health research has an essential role to play for improving knowledge about which delivery strategies should and can effectively and efficiently be employed.  More specifically main messages included: • Different concepts on governance and sometimes “good governance” prevail. Certain participants see governance as a value overriding health de-velopment or as a means to achieve better health outcomes and still others identify the main interest in governance as a process accompanying health service planning and management;  • Equity as a main concern which has to govern health action. However, sometimes the terms “equality” and “equity” were understood interchangeably and little difference was made between equity in the mobilisation, allocation and utilisation of resources and the alignment of these different dimensions of equity.  • The GEH initiative offers a potentially rich source for networking, ex-change and concerted action across different research groups. However, modalities and the added-value of these collaborations still need to be better detailed;  • Effective communication from research to policy-making and vice versa is seen by some GEH funded research groups as an important starting point to bridge the gap between knowledge and action for health. These re-searchers see RM within GEH as an important opportunity to disseminated and capitalise their activities and results through effective dissemination to policy makers. Other groups do have a more classical understanding of re-search and conceive the finality of research as broadening the scientific knowledge, e.g. through peer-reviewed publications, without promoting direct interactions between research and research users. Thus the conference could not establish a clear consensus on the potential of RM in closing the loop between research and action.    6Options for GEH and RM with regard to the health fi-nancing theme  This section discusses options for GEH and RM coming out of the meeting on “Governance” – the interplay between health, equity and financing in view of upcoming opportunities for GEH to fund research in the area of health financ-ing. A first such opportunity is offered to GEH through the “Dar Es Salaam meeting” in May 2005 on user fees and health financing strategies. More specifically  oppor-tunities for GEH and RM in the area of financing can be identified at the following levels: • GEH offers flexible and non-bureaucratic mechanisms for funding re-search in the area of health financing.  • GEH and RM can be responsiveness to requests (e.g. from the policy-making arena). In other words, GEH can respond in a timely fashion to up-coming demands and need for evidence for decision-making;  • GEH and associated research groups are close to decision-makers and have expertise in research and in establishing the bridge to policy-making through effective communication  • GEH joins the concepts of Equity, Governance and Health and thereby ad-dresses and aligns crucial components of financing for health systems strengthening;  While funding research and rapid responses to emerging questions in the area of health systems strengthening including in health financing, considerations which GEH and RM will have to keep in mind consist of: • Limited funding: While GEH can provide relatively large amounts for project funding for researchers and research groups, most of grants within RM will be limited and be in the range of $ 10’000;  • Time-scale of research: In order to be responsive to identified needs and demands, there will be a high pressure on GEH to deliver research results within short timelines. While the production of scientific results within re-stricted time-scales depends on the research question under investigation, various research methods and approaches do allow the timely production of results of good quality.  • Quality criteria of research need to be respected (even in the context of rapid responses to emerging research questions) and there need to be clear differences between studies established through consultancy work and re-search funded under GEH. It has to be avoided that the credibility of research is undermined. Generally spoken, research activities are underlined either through research hypothesis or question, and GEH should unmistakably re-quest from research and research groups that they adhere to research princi-ples;  • Funding of “case studies”: While the prime focus of research may vary from sub-regional, national to sub-national level, GEH offers the opportunity to es-tablish case studies which provide evidence and feed into health priority set-ting and decision making;   7• Complementarity and specificity compared to other actors/institutions active at the interface research capacity strengthening and health economic research/health systems strengthening or at the level of evaluation & monitor-ing (e.g. World Bank, DFID, etc.). In some cases it will be necessary before funding through GEH to map on-going and planed research in order to avoid duplication.  • Promotion of an added-value at the level the GEH initiative: As pointed out earlier the added-value of GEH and RM potentially lies at the level of the establishment of framework, analysis, comparison, and communication across individual research projects. Consequently, GEH may seek funding opportunities which complement and link into on-going research activities thereby creating exchange and capitalisation across projects.  At the current point of time GEH, should not restrict itself thematically and re-main open to emerging research questions in the area of health financing. An important principle of funding may be the demand-driven nature of GEH response to research. Nevertheless, based on the conference discussions and a paper estab-lished by Hutton1, possible research entry points and questions for GEH are:  • How the donor agenda and national priorities/ownership interact? As there are various examples that donors follow their own agenda, irrespective of the national priority or defined activities (e.g. debate on user fees in Tanzania), how these interactions do materialise?  • Success as well as failure stories of recipient governments’ attempts to coor-dinate donors (and eventually the private sector) and pool resources specifi-cally in the area of HIV/AIDS. Further, how donor policies and funding mechanisms interact and what are the complexities which surround parallel project funding, funding through Global Health Initiatives and funding under Sector Wide Approaches?  • Pooling of funds through Sector Wide Approaches: What is gained by con-tributing to a pooled fund instead of giving to the government budget (whether at sector or MOF level)? What are some pre-conditions for pooling funds? What are the effects, including effects over time, on governance and equity of some donors being outside the pool/regular budgetary allocations (e.g. PEPFAR, foundations)? What are the main threats of pooled funding? E.g. some contributors to the pooled fund may not permit certain types of funding (e.g. external funds for TA and NGOs in Bangladesh), which may lead to mul-tiple pools & increased transaction costs. Pooling and procedures: What are the disbursement conditions and practices within pooled funding which allow for flexibility to unforeseen problems.  • ART and rationing of service provision: What decision criteria are used and on what values are they based on? Which groups are eligible to ART and why? Who is excluded and why?  • Financing and health systems strengthening o Evidence that ART may contribute to health systems strengthening. Are examples of additional funding for ART contributing to systems                                                 1 Hutton G, Wyss K. 2005. Strengthening health systems in Southern and East Africa in the context of scaling-up HIV/AIDS interventions: Resource flows, aid modalities, intervention scal-ing up, and equity. A paper established in the frame of the SDC Backstopping Mandate 2004 of the  Social Development Division's Health Desk & IDRC and SDC funded initiative on Governance Equity and Health (GEH) and Research Matters (RM). Swiss Tropical Institute. 60 pages  8strengthening, for example through the up-scaling of skills of human resources? How ART funding can contribute to better planning and management of health services, e.g. at district level? What is the role and contribution of the private profit and non-profit making sector in funding and providing ART services? o Evidence that ART can contribute to the integration of services. What are success stories of integration of ART in (basic) service packages? At which level (referral hospital, district hospital first contact facility) ART services are most successfully integrated? o What are the effects of PEPFAR and other Global Health Initiatives such as the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria on health systems?  Whichever principles and research topics are selected by GEH, the above list is in no way exhaustive but implies that health research has a crucial role to play to allow for research capacity development and generating evidence  including in the area of health systems research and financing.   9

Post conference report with special consideration of main messages coming out of the conference and suggesting action options for GEH and RM with regard to the health financing : "Governance" - the interplay between health, equity and financing, Saly, 25-30 Apr. 2005

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Post conference report with special consideration of main messages coming out of the conference and suggesting action options for GEH and RM with regard to the health financing : "Governance" - the interplay between health, equity and financing, Saly, 25-30 Apr. 2005

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