Health financing: UHC, social health protection, technical efficiency and addressing hospital challenges

This series of health financing technical seminars organised by the Oxford Policy Management (OPM) Health team, in partnership with HEART, examined how the globally evolving health financing expertise can translate into advances that national health systems make towards Universal Health Coverage (UHC). More specifically, seminars brought together health financing experts from across the spectrum (government, academia, think tanks, international organisations and consultancies) in a joint reflection on how the global UHC health financing discourse can be pragmatically translated in country-level health financing decisions and implementation. Seminars  focused on fiscal space for health, social health protection mechanisms, technical efficiency and addressing hospital challenges.

Seminar 1: Health service costing and fiscal space analysis
Oxford, 17th June 2016

Universal health coverage (UHC) has amassed widespread political support from global and national leaders alike, being expected to retain the momentum throughout the SDG agenda. Considerable financial resources are required to pursue UHC and several global benchmarks for government health expenditure have been proposed (e.g. 5% GDP, $86 (2012) per capita), primarily for advocacy purposes. However, for most low- and lower-middle-income countries the gap between current government health expenditure and what would be required for a package of essential interventions in line with UHC is downright prohibitive.

Fiscal space analysis is a useful tool for identifying options for closing the resource gap along four key directions (‘the fiscal space diamond’): health aid, government debt, efficiency savings and domestic spending. Simulation exercises conducted at a global level suggest that closing the resource gap is unlikely without sustained/augmented health aid, particularly in low-income countries.

This seminar brought together thinkers and country decision makers to reflect on the question “How should national policy makers approach the development and deployment of health financing strategies for UHC, with a view to sustainability, efficiency and equity?

Its specific aims were to:

  • Reflect on how the global UHC health financing discourse can be pragmatically translated in country-level health financing decisions and implementation using sector costing and fiscal space as tools
  • Summarise lessons from country experiences
  • Discuss technical approaches to conducting fiscal space analyses and how to complement them with other analyses.


Seminar 2: Social health protection
London, 27th June 2017

The essential roles of public financing mechanisms in general and of prepaid contributions in particular for advancing towards universal health coverage (UHC) have been increasingly recognised by governments, donors and researchers alike. Social health insurance (SHI) and taxation are two fundamental mechanisms for raising prepaid contributions and quite a few low- and middle-income countries (LMICs) are currently at various stages of introducing some form or combination of these mechanisms.

There has been less research on the practical implementation details of social health protection (SHP) schemes compared with theoretical foundations of health financing for UHC. Collecting contributions in large pools to avoid fragmentation, focusing on equity from the outset by including the poor, and improving the efficiency of tax collection and health spending are examples of largely undisputed principles – less is known, however, of how such principles can be realistically enacted while accounting for country context. Other relevant considerations relate to ways of reaching the informal sector, the role of private sector provision, shifting from passive to strategic purchasing and ensuring technical capabilities for monitoring SHI. Deploying such complex reforms takes substantial time and resources, and there is no blueprint for preparing, designing and overseeing their implementation.

This seminar brought together leading thinkers and practitioners of SHP in LMICs to reflect on how the latest implementation evidence can systematically translate to the practice of designing and introducing SHP schemes in LMICs. Three broad questions were addressed with a view to past and ongoing country experiences:

  • What does it take to prepare for the introduction of nationwide SHP schemes?
  • What considerations are pertinent to the policy decision for SHP and for a given design, in combination with tax-based approaches?
  • What are the SHP implementation challenges once the policy decision has been made, and what are their potential solutions?


Seminar 3: Technical Efficiency
15th September 2017

Improving the effectiveness of available health resources in LMICs has increasingly become important as many countries attempt to map out their paths towards achieving UHC. For many of these countries, a combination of increased health coverage targets, increased disease burden from communicable and non-communicable diseases, and sometimes reductions in global support towards the health sector has enhanced the need to improve value for money in the health sector. Indeed, the growing body of literature on measuring health system efficiency shows large variations in efficiency within and across health systems – highlighting the potential for health systems to improve efficiency. Yet, a number of challenges remain in achieving technical efficiency across and within health systems.

First, while there is a growing literature on the sources of inefficiencies in health, it is not yet clear to whom policy interventions to address these should be targeted to achieve the greatest impact. The Ministry of Health (MoH) is the custodian of the health sector but often some of the main causes of inefficiency lie outside the jurisdiction of the MoH – Human Resources for Health being one prime example – which often lies within the Ministry of Public Service (or related). The second relates to methodological challenges in quantifying efficiency in a given sector. Methods to compare health efficiency across health sectors are becoming more standardised (e.g. DEA and Stochastic Frontier Analysis), but the quantification of this remains difficult.

Participants came together to reflect on the question “How can country-specific evidence on the sources and magnitude of health system inefficiency inform policies that enable a better use of available resources?

The seminar’s specific aims were to:

  • Reflect on how the most  pressing sources of inefficiency in a particular health can system be identified
  • Identify which stakeholders have decision making power over the major sources of health system inefficiency, and how can they be brought in to the discussion on health system inefficiency
  • Discuss ways on how progress on efficiency initiatives can be monitored


Seminar 4: Addressing hospital challenges in low- and middle-income countries
7th November 2017

This seminar, hosted by OPM and supported by DFID, brought together a group of hospital professionals (top academics, hospital managers and international consultants) to discuss challenges in hospital governance, administration, and financial management in LMICs and to reflect on the question: “Why invest in hospital sector improvement?”

Regardless of standpoints and the diversity of expertise, participants spoke unanimously about the need to ‘rethink hospitals in contemporary health systems’. This, in a context of public- private engagement and unavoidable scarcity of resources needed to deliver high-quality services, would streamline the understanding of hospital governance, institutional arrangements, business models and models of care.

Read more about this seminar here.


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