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Written by Martha Coe (Program Manager, ThinkWell) and Anupama Tantri (Executive Director, Global Vaccine Public Policy Development; Merck Sharp & Dohme Corp.) 

Fifteen months into the global COVID-19 pandemic, the tie between public health and the economic value of disease prevention and immunization has never been more apparent. The world is looking to vaccination to help prevent illness, hospitalization, and death from COVID-19 as well as reopen economies.

The Asia-Pacific Economic Cooperation (APEC) Life Sciences Innovation Forum recently hosted a webinar to explore how countries can unlock and leverage funds for COVID-19 vaccination and across the life-course moving forward. ThinkWell and Merck Sharp & Dohme Corp. (MSD) were pleased to take part in the webinar and build on our ongoing work on sustainable immunization financing. Moderated by Anupama Tantri from MSD, the three expert panelists, Dr. Chunhuei Chi from Oregon State University, Dr. Mursaleena Islam from ThinkWell, and Dr. Ping-Ing Lee from National Taiwan University, provided insights and recommendations on how best to secure and leverage financing for COVID-19 and for immunizations across the life-course, including:

  1. Invest in public health systems and infrastructure to achieve equitable access,
  2. Use robust and actionable economic evidence to mobilize and allocate resources efficiently, and
  3. Improve awareness of the value of vaccination among decision-makers to mobilize resources and justify investments.

1. Invest in public health systems and infrastructure to achieve equitable access

Availability is not the same as accessibility. At the outset, Dr. Chi noted that even if countries have procured COVID-19 vaccine doses and have them available in country, they may not be reaching all their populations in need. For example, barriers in delivery systems can postpone availability for certain geographies or hourly wage workers may need vaccination sites to be open at different hours than their work shifts in order to get vaccinated.

To ensure rapid and equitable access to COVID-19 vaccines, countries need to invest in the following three areas:

  • Infrastructure to reach new populations or those in underserved or hard-to-reach areas. This includes expanding sites where vaccines are administered and ensuring that the cold chain and supply chain can support these new sites.
  • Human resources to staff new or expanded vaccination sites and enhance outreach efforts to increase uptake.
  • Information systems to track vaccination status and help assess the impact of vaccination in protecting vaccinated individuals from COVID-19, as well as in preventing transmission.

These investments can have long-serving impact beyond the pandemic to strengthen equitable access to other vaccinations across the life-course. For some countries, the pandemic has made apparent the fragility of and gaps in their public health infrastructure. Investments to respond to the pandemic provide an opportunity to have broader impact on immunization programs and public health.

2. Use robust and actionable economic evidence to mobilize and allocate resources efficiently

Securing sufficient and sustained resources for routine immunization requires costing and budget information that is specific to the country context and use-case. Dr. Islam shared three real-world case studies, conducted by ThinkWell with country and multilateral partners, that demonstrate the criticality of contextually relevant economic evidence to secure the resources needed for both routine vaccination and COVID-19 priorities.

  • The first case study looked at the use of costing data to secure the resources necessary to deliver routine vaccination services safely during the COVID-19 pandemic. COVID-19 precautions (e.g., personal protective equipment and other infection control measures) were found to increase the cost of delivering routine immunization services by 20% to 129%, depending upon country and delivery specifics. Based on this data, government and other decision-makers could better plan and allocate resources for delivery.
  • The second case study demonstrated the importance of accurate costing data to support COVID-19 vaccine roll out. The COVAX Working Group developed robust cost estimations for COVAX member countries and donors on the incremental delivery costs for COVID vaccines across all 92 Advance Market Commitment (AMC) countries. Robust costing and modeling found that it will cost US$1.66 to deliver each dose. This information helped the World Bank support resource allocation and prioritization.
  • The third case study zoomed in on Indonesia and the use of budget data to protect routine immunization programs during the COVID-19 pandemic. ThinkWell researchers worked with the Indonesia Ministry of Health and local-level managers to improve visibility of COVID-necessitated budget reallocations on routine immunization services. This work found that routine immunization budgets declined across all of the assessed districts, but the magnitude of decline varied. The results informed detailed recommendations for decision-makers in Indonesia’s Ministry of Health to be able to respond to COVID-19, as well as maintain routine immunization programs. This case study also underscored the importance of understanding sub-national level costing information to ensure that vaccines reach the last mile and programs achieve equitable access to COVID-19 and routine vaccinations.

3. Improve awareness of the value of vaccination among decision-makers to mobilize resources and justify investments

The full health, economic, and societal benefits of immunizations should be captured and reflected in value assessments and funding decisions. As Dr. Lee noted, many middle-income countries have gaps in the vaccines available through their public immunization programs. Immunization programs must compete for resources alongside many other health interventions, and greater awareness and evidence on the value of vaccination can help to improve the prioritization of and allocation of resources to fill these gaps. Dr. Lee noted that traditional cost-effectiveness analysis may not take into account the broader, more comprehensive benefits of vaccination. Greater awareness among policymakers, health care providers, and the public of the broad returns on investment is necessary to support resource mobilization for, as well as access to and uptake of vaccination services. A variety of channels can be used to reach these audiences including public education, the media, and medical education.

If you want to learn more about ThinkWell’s work in sustainable immunization financing, you can read about it here.

You can watch the full webinar recording below. You can view the accompanying slides here.

This blog was produced by ThinkWell in partnership with and funding from Merck Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA. The views and opinions expressed by the panelists are their own and do not necessarily reflect the views and opinions of ThinkWell or MSD.

This piece originally appeared on P4H here. 

This blog, written by Tapley Jordanwood (ThinkWell), Aliyi Walimbwa (Ministry of Health, Uganda), Anooj Pattnaik (ThinkWell), and Angellah Nakyanzi (ThinkWell), highlights an extensive study of the latest two reproductive, maternal, and newborn health (RMNH) voucher schemes in Uganda conducted jointly by the Uganda Ministry of Health and the Strategic Purchasing for Primary Health Care project implemented by ThinkWell with support from the Bill & Melinda Gates Foundation.

Guided by a primary health care (PHC) philosophy, Uganda’s public health delivery system is designed to provide free services at the point of utilization, but the system is under-funded and ignores capacity in the private sector. Many public facilities consistently suffer from inadequate staffing, medicines, and supplies to provide their mandated range of services. Government purchasing arrangements for health services currently engage both public and faith-based networks of facilities; however, not included are private for-profit providers that constitute nearly half of Uganda’s health facilities. These private for-profit providers mostly deliver PHC services and have minimal coordination with the public system. With limited options, many women do not have access to essential reproductive, maternal, and newborn health (RMNH) services either because services are not available in the public system or are not affordable from private providers.Thus, it is not surprising that RMNH access and outcomes are not optimal in Uganda. While there have been consistent improvements and Uganda is lower than the average in sub-Saharan Africa, both maternal and neonatal mortality in Uganda remain high by international standards. Uganda has the fourth fastest-growing population globally, with an estimated 1.5 million children born every year and 75% living in rural areas. Affordable access to high-quality maternal care is a significant problem in Uganda; 36% of deliveries by women in the lowest two wealth quintiles took place outside of a health facility.

With support from donors, Uganda has implemented a variety of voucher schemes, which offer more than a decade of context-specific learning on health purchasing that could inform the proposed national health insurance scheme (NHIS). The Parliament of Uganda recently passed the 2019 NHIS Bill, which now awaits Presidential approval to establish the NHIS as a new demand-side health financing mechanism. This pivotal health reform would create a purchaser-provider split, contract public and private providers, and establish a benefits package— all essential functions that the voucher programs successfully implemented at a large scale. As the last two voucher projects drew to a close, the Ugandan Ministry of Health and ThinkWell undertook a joint study and published an extensive report that documents how these voucher schemes functioned and performed to draw lessons for future demand-side financing efforts, including the planned NHIS.

The Ugandan voucher schemes were designed to provide rural poor pregnant women with affordable access to high-quality essential RMNH services. The latest two donor-funded voucher schemes supported over 400,000 safe deliveries in just over three years. Covering 28 (out of 135) of Uganda’s districts, the second Uganda Reproductive Health Voucher Project (URHVP-II) was financed by the World Bank through the Global Partnership on Output-Based Aid and ran from June 2016 through October 2019. The USAID-funded Uganda Voucher Plus Activity (UVPA) started slightly later in October of 2016 and ran through March 2020, covering 35 districts. Set up as independent purchasers of services, the schemes fielded teams of village-based voucher distributors who identified poor women, provided them with health education, and then sold them vouchers at highly subsidized prices. Identified women then redeemed their vouchers primarily at selectively contracted private for-profit health facilities (in addition to some public and private non-profit facilities) to access a package of RMNH services. Contracted providers were then reimbursed by the voucher schemes based on the services rendered.

Within Uganda’s fragmented health delivery system, voucher schemes pioneered service networks that integrated private, public, and non-profit facilities. Selectively contracted facilities were organized into service delivery networks to ensure affordable access, accountability, and adherence to service quality standards. A critical step forward in this effort was the successful linking of private for-profit providers to both public and private non-profit facilities in the health system. The voucher facility networks of providers facilitated cooperative actions between facilities, including improved referral systems for complications and emergencies.

Providers reinvested their revenue from the voucher schemes to increase their facility capacity and improve their quality of care. By paying facilities fair rates based on the cost of care, contracted facilities had the resources and autonomy to ensure sufficient staffing and medical supplies to meet demand. The combination of clear quality standards, regular measurement, field-based technical support, and contractual consequences led to significant improvements in quality.

The voucher schemes were vivid demonstrations of what is required to establish a demand-side financing mechanism. Establishing a new financing mechanism that will purchase service outputs requires new institutional roles, modalities, contracts, and financing systems. Examples in South Korea and Taiwan have demonstrated that years of implementing voucher programs can lay the groundwork for building an NHIS to support universal health coverage efforts. As Uganda takes its first steps to establish its own NHIS, critical choices to determine the institutional setup, initial benefit package, service delivery contracts, and claims management systems need to be made. The voucher schemes provide a large-scale demonstration of what it takes to set up a demand-side purchaser.  These experiences have generated hard evidence to inform Uganda’s choices as it establishes the NHIS going forward.

One of the proposals in the 2021 National Hospital Insurance Fund (NHIF) Amendment Bill stipulates that all Kenyans must be registered under NHIF in the new Universal Health Coverage (UHC) program.

When this news broke in mid-February, the media balked. Much of the uproar was in response to mandatory NHIF enrollment. Many Kenyans believed that it’s unfair to require all households, including the poor, to pay the premium. The concerns raised by Kenyans warrant reflection.

First some background. This bill is part of a Government of Kenya (GOK) plan for achieving UHC. The goal of the UHC program is to provide health care for all based on need—not on ability to pay. It is predicated on NHIF becoming a national health insurance scheme that is mandatory for all.

Formal sector employees currently make mandatory NHIF contributions on a graduated scale, which covers them and their families. Informal sector households can sign up for NHIF by contributing Ksh 6000 per year. The “universal” part of GOK’s UHC plan is its commitment to cover the poor. The target is to eventually cover all five million poor households, but GOK has committed to start this year with covering one million poor households.

To expand NHIF’s mandate to offer UHC, the proposed bill seeks to increase the revenues raised by NHIF in three ways: 1) making NHIF mandatory for all, 2) requiring employers to match their employees’ NHIF contributions, and 3) for co-insured patients, providers will be required to bill the private insurer first before NHIF pays.

Let’s explore these three key elements of the proposed legislation that relate to the question of equity.

Mandatory NHIF membership

By explicitly including the word “mandatory,” the bill makes it clear that NHIF is mandatory. In theory, NHIF has been mandatory since the NHIF Act of 1998, which states that any “ordinary resident of Kenya,” whether “salaried or self-employed,” shall be “liable as a contributor” to NHIF. In practice, however, NHIF membership for informal sector workers—who constitute 83% of Kenya’s workforce—has remained voluntary.

Mandatory NHIF coverage would raise revenues for UHC and improve prepayment and financial protection. Currently, only about 20% of Kenyans have any form of health insurance coverage, with over 85% of them covered by NHIF. NHIF coverage among the formal sector is near universal, compared with only 15% NHIF coverage among the informal sector.

Since the informal sector is not organized, it has proven administratively difficult to recruit and collect regular contributions. Retention of informal sector workers has also proven difficult, and drop out rates among this group of members remains high.

So what might change now?

The bill gives NHIF and the Ministry of Health new powers to enforce premium collection, particulary among the informal sector. Some possible ways of enforcing NHIF enrollment would be requiring proof of NHIF membership to obtain an ID card, to enroll your child to school, or get other government licences and services.

That may work, but it poses some risks of hurting the poor who have not yet been brought into the NHIF subsidy. During this first year of UHC implementation, the government will sponsor one million poor households, leaving about 4 million poor households without coverage. What happens to them during the period when the subsidy is not scaled up, but NHIF starts enforcing the new rules? And isn’t it unfair to the near-poor, who have to pay the same exact amount as a rich farmer or businessman?

Employer contributions

The proposed law requires employers to match their employees’ NHIF contributions. This is a game changer that would double the premiums received by NHIF from the relatively affluent members of society, namely those employed in the formal sector. These resources would improve NHIF’s financial sustainability as well as its redistributive potential.

On the flip side, this would considerably increase the labor cost of doing business in Kenya, which is already deemed high in comparison to Kenya’s GDP, and to the labor cost in neighbouring countries. This could hurt Kenya’s competitiveness and could have a detrimental effect on the private sector, which may reduce jobs to meet these new demands or move businesses to other countries. If that happens, it could worsen the already dire unemployment situation.

Because of these reasons, this proposal is likely to be met with a lot of resistance from the private sector.

Changing how NHIF pays out

In situations where clients have both private insurance and NHIF, private insurance providers would be required to first exhaust their coverage before NHIF pays any outstanding amounts subject to the “funds applicable limits” (though NHIF would still pay the daily inpatient rebate). This is an interesting twist and a reversal of the current practice.

When NHIF expanded the benefit package in 2016 to cover outpatient, surgeries, radiology, and other services, private insurance companies quickly saw an opportunity. They stipulated that NHIF act as the primary insurer for co-insured members, thereby bearing the biggest component of medical bills. In many ways, NHIF funds were used to subsidize private insurance.

Anecdotal evidence is that the tariffs for health services, especially in the private sector, went up as “more” funds became available. NHIF also ran into solvency problems and was not able to meet claims, leading to delays in claims reimbursement.

If this bill is passed, more funds would be available for NHIF to possibly expand the benefit package and honor claims. On the flip side, it could also lead to private insurers raising their premiums or reducing their limits, forcing NHIF to pay the residual amount.

Moving forward

The move to provide universal health coverage is noble, but the success of the UHC program depends largely on a reformed NHIF, improved service quality, and leaving no one behind. Urgent reforms are needed that improve efficiency, transparency, and accountability at NHIF. NHIF will need to improve its engagement and communication with the public and with providers; this is one of proposals stipulated in this bill. NHIF also needs to strengthen the way it pays providers by incentivizing quality healthcare.

The GOK needs to address the coverage of the poor and vulnerable. So far, the GOK has made plans to sponsor one million poor and vulnerable households, which is roughly four million people. While this is a step in the right direction, there is still much work to do given that roughly 18 million Kenyans live below the national poverty line. If the reforms proposed in this bill see the light of day, the additional funds could go a long way towards providing UHC.