By Obaid Khan and Sven Engels

If policymakers in Pakistan are serious about achieving universal health coverage (UHC), it is important that smart investment decisions are made, guided by evidence. Like many countries worldwide, Pakistan has embraced the global goal of realizing UHC by 2030 as part of its commitment to the Sustainable Development Goals (SDGs). UHC means that all people can obtain the health services they require without facing financial hardship. To achieve this, prioritization of health investments is critical, especially in the context of limited fiscal space, a common struggle across many low- and middle-income countries. To maximize the impact of each rupee spent on the health care system, the focus should therefore be on the most cost-effective interventions that address the most critical health needs of the population.

The need for evidence-based prioritization of health investments in Pakistan

Recent controversies over the procurement of robotic surgical systems in Pakistan’s Sindh province highlight the issue of ‘misplaced priorities’ and the urgent need for a systematic approach to prioritizing investments in the health system. The debate over allocating billions towards robotic surgery raises the fundamental question: What should the top priorities be when investing public funds in the health system? While robotic surgery is a marvel of medical technology, its high cost and highly specific use cases raise concerns about whether it offers good value for money, particularly in a country where the basic health care needs of millions remain unmet.

Identifying high-impact health services

When budgets are tight, one should focus on the essentials. But what exactly constitutes “essential” health care? Fortunately, there is international guidance to help answer this question. The 3rd edition of Disease Control Priorities (DCP3), a periodic publication which reviews the most cost-effective health interventions, defines essential health care services as those that provide good value for money, address a significant disease burden, and are feasible to implement. In addition, these services should be delivered to the entire population in an equitable manner, in line with the principles of UHC. Based on these criteria, DCP3 identifies 218 essential health services, of which 70 percent are provided at the primary facility level, although the final selection can vary based on local context and priorities.

Developing a customized Essential Package of Health Services

In 2020, Pakistan leveraged the guidance of DCP3 to develop a national Essential Package of Health Services (EPHS), prioritizing interventions based on the country context. Subsequently, the national EPHS was customized by Pakistan’s provinces, with each province prioritizing the interventions according to their contextual realities, such as the local disease burden, special needs, and available fiscal space. As Pakistan moves forward with its UHC agenda, it will be crucial to recognize that while the development of the EPHS provides a strong foundation, the real work of transforming the health system and improving health outcomes will happen during the implementation phase, which will require a concerted effort to overcome challenges and maintain momentum.

Realizing good value for money through a focus on primary health care

Crucially, the EPHS emphasizes the importance of prioritizing interventions that can be delivered at the primary health care level, where resource needs tend to be lower but where the greatest impact on population health can be realized – offering strong value for money. Investing in primary health care therefore offers a compelling value proposition, particularly for countries with limited fiscal space, such as Pakistan. By investing in primary and community-based health services, Pakistan can target the root causes of illness, thereby also reducing the burden on secondary and tertiary care facilities.

The cost of implementing the EPHS is modest compared to the potential benefits it offers. Although it will cost only $13 per capita annually (national EPHS 2019 estimates) to implement 88 immediate priority interventions at district-level, the EPHS will benefit large parts of the population, unlike investments in niche, high-tech medical interventions like robotic surgery. In addition, the impact of investing in essential health services is far-reaching, as it improves health outcomes and reduces disparities throughout the country, thereby making real progress towards UHC. A back-of-the-envelope calculation shows that the procurement costs of four surgical robotic systems at PKR 4.25 billion (US$15m), expected to enable the delivery of a few hundred surgeries annually, could instead be used to provide a package of 88 highly cost-effective essential health services at the levels of community, PHC center, and first-level hospital to about 1.17 million people for a year.

Ensuring success and sustainability of the EPHS

The formulation of an evidence-based EPHS is certainly a vital step forward in Pakistan’s quest for UHC, but it is by no means the end of the road. The real challenge lies in its implementation, which is arguably the most complex piece of the puzzle, requiring difficult choices and trade-offs. In this regard, policymakers in Pakistan, including those at the provincial level, should consider a few key questions. How many of the 218 essential health services defined in the national EPHS can realistically be implemented given financial and institutional constraints? Do provinces have capacity to identify and address gaps between what health services are delivered in practice versus those included in the package? And how do these gaps differ across sub-provincial and district levels? Moreover, governments must continually adjust their priorities based on local evidence and available financial resources. Addressing system-level deficiencies in the health system is crucial for effective delivery of the full EPHS, and this may require mobilizing additional resources, possibly through development partners and/or private sector actors. Ensuring sustained political and administrative buy-in for these reforms is essential, as is monitoring and evaluating their progress. And ultimately, institutionalizing these initiatives in government’s budget and long-term strategic priorities is essential for their success and sustainability.

Final reflections

The formulation of the DCP3-guided national EPHS for prioritization of essential health services demonstrates Pakistan’s commitment to achieving UHC. However, the package formulation needs to be followed by a robust implementation plan to deliver these essential services. With health being a provincial subject in Pakistan, sustained political and administrative commitment at the sub-national level will be critical. The country’s limited fiscal space also necessitates a comprehensive strategy for domestic resource mobilization to finance the prioritized essential services.

Realizing the full potential of the EPHS and making strides towards UHC in Pakistan will require more than just good intentions. It will demand sustained political commitment and accountability coupled with a data-driven effort to monitor progress, identify barriers, and adapt to changing circumstances. By maintaining a sharp focus on cost-effective interventions delivered through primary health care and grounding decisions in local evidence, Pakistan can ensure that its health investments yield the greatest possible impact and drive meaningful progress towards UHC.

Webinar, June 18, 2024

2-3:30PM-Kampala (11:00AM-UTC)

In recent years, results-based financing (RBF) has emerged as a context-specific transformative approach to development, revolutionizing how governments allocate resources for health. With its emphasis on delivering tangible and measurable results, RBF has gained significant attention as a mechanism to enhance the effectiveness and efficiency of development interventions through increasing financing for health. In Uganda, the integration of RBF within the mainstream primary health care (PHC) financing framework has opened new avenues for accelerating progress towards the global universal health coverage (UHC) agenda.

On June 18, the Makerere University School of Public Health (MakSPH), the Uganda Ministry of Health (MOH), and ThinkWell hosted an insightful webinar that delved deep into the journey of RBF from a project to a mainstreamed approach in Uganda. This webinar was designed to provide a comprehensive understanding of how RBF is shaping development initiatives, fostering innovative financing, and driving sustainable positive change in Uganda’s health sector.

Watch recording

Download Dr. Tabusibwa’s presentation

The panel comprised two presentations followed by a broader discussion session, ensuring a comprehensive exploration of the journey and implications of mainstreaming RBF within Uganda’s development landscape and what this means for global practice.

A dynamic panel discussion brought together experts, practitioners, and webinar participants to engage in a lively exchange of ideas. Through this approach, the webinar provided a holistic view of the RBF mainstreaming journey in Uganda, offering attendees a comprehensive overview of the challenges and harness the opportunities presented by this innovative financing model within the broader context of financing for PHC. Attendees had the opportunity to interact directly with the panelists, enriching their understanding and fostering a collaborative environment for knowledge sharing.

Panelists, presenters & moderator

  • Dr. Sarah Byakika, Commissioner of Health Services, Planning, Financing, and Policy, Ministry of Health (panelist)
  • Prof. Freddie Ssengooba, Professor of Health Economics and Health Systems Management, Makerere University School of Public Health (panelist)
  • Dr. Muhammed Mulongo, Senior Medical Officer & Ag District Health Officer, Bulambuli district (panelist)
  • Dr. Eric Tabusibwa, Team Lead, RBF Unit – Ministry of Health (presenter)
  • Ms. Christabel Abewe, National Professional Officer, Health Financing, World Health Organization Uganda (panelist)
  • Ms. Angellah Nakyanzi, Country Manager – ThinkWell Uganda (moderator)

By Nirmala Ravishankar (ThinkWell), Edwine Barasa (KEMRI Wellcome Trust Research Programme), Sophie Witter (Queen Margaret University), Angellah Nakyanzi (ThinkWell), and Joseph Kutzin (WHO)

There is a growing consensus among health financing specialists that low- and middle-income countries (LMICs) should ensure that government-owned health facilities receive some public funding directly and have the flexibility to spend it. The term direct facility financing (DFF) has come to be associated with such reforms that have drawn support from the Lancet Global Health Commission on financing primary health care and garnered attention from both donors[1] and country governments.[2]

Even as the DFF conversation gains momentum, it is critical that lessons from performance-based financing (PBF) reforms that were tested widely in many LMICs are not lost. At a conceptual level, PBF and DFF share many common attributes, and the use of different labels can be confusing. The translation of these concepts into actual practice has been different, however. And the discourse around PBF projects offers a vital lesson for DFF reforms: the importance of a systems approach.

The history of facility financing arrangements

Historically, LMIC governments used input-based budgeting to pay for health care at public facilities. Over time, stagnating health budgets, low execution rates, and leakage resulted in few funds reaching frontline facilities. Encouraged by international agencies in the 1980s, many LMICs introduced user charges and payments for drugs along with changes enabling facility managers to use these funds. While the fees gave facilities some flexible financing, they became a financial barrier to access for the poor. This set the stage for facility financing mechanisms geared towards removing user fees while maintaining their productivity incentives and the facility management autonomy that accompanied them.

The most popular were reforms bearing the PBF labelRwanda was the first among LMICs to adopt PBF country wide. Successful advocacy and donor funding resulted in the approach spreading to 36 LMICs. Reforms bearing the DFF name were less numerous. Kenya and Papua New Guinea were among the early adopters of DFF, and a few countries including Nigeria, Cameroon, and Zambia introduced a package of interventions labelled DFF as a “policy counterfactual” to PBF. In recent years, DFF has come to be closely associated with Tanzania, which scaled up DFF nationally.

Conceptual similarities

PBF and DFF share many characteristics. They both involve public funds flowing to facilities to cover some operating costs, even as the government directly pays for the bulk of core costs, such as staff salaries. Both are complex reforms that include other interventions like increased facility autonomy and community engagement.

As noted above, several countries tested PBF and DFF side by side. The key difference was that payments under PBF were linked to performance measured using output and quality indicators and in many cases facilities could use some of it to pay bonuses to staff. Studies found that they delivered comparable improvements, but DFF costed less and was easier to implement. The two approaches are not dichotomous, however; DFF with its emphasis on funds flows and operational autonomy can be foundational, while performance incentives à la PBF could be worked into the payments eventually.

An important practical difference

More has been written about PBF, and a key part of the discourse has focused on how PBF reforms have been implemented. Its proponents characterized PBF as a system-wide reform. Its critics feel PBF reforms have been “donor-driven fads” implemented in “project mode” and have fallen short of this promise.

For example, PBF schemes relied on new structures to verify results instead of strengthening existing information systems, and the payments were not aligned with public financial management (PFM) rules. Many PBF pilots were narrow, focusing on select services based on the donor funding them. These characteristics increased costs and hurt government buy-in, making the schemes unsustainable.

The way forward with facility financing reforms

A recent brief by the World Health Organization and the World Bank recommends that DFF be viewed as a systems reform instead of a new project or scheme. We agree but worry that old habits die hard. So, as the wind gathers behind the DFF sail, we offer three concrete recommendations:

  1. DFF can take many forms. The point is not to introduce a new scheme or provider payment method called DFF. Instead, the goal should be to analyze existing facility financing arrangements and find ways to strengthen desirable health financing attributes associated with DFF, such as funds for operations flowing directly to facilities and facility managers having the authority to manage these funds. Indeed, in some contexts, this may entail transitioning existing PBF projects.
  2. DFF must happen within the system. The reform being integrated into PFM rules, governance arrangements, and information platforms is inherent to DFF and critical for ensuring its sustainability.
  3. DFF reforms should target a comprehensive range of services. While it is nonsensical to have a parallel DFF platform to channel only donor funds for vertical programs, DFF can support the harmonization of donor inflows with domestic public budget financing for health. This can unify payments to offer a coherent incentive environment for providers.

Following these suggestions will ensure that DFF is not viewed—negatively or positively—as the new silver bullet, and instead becomes the engine for meaningful and lasting health reform.

[1] USAID, Global Fund, GAVI, and the World Bank are supporting countries implement DFF reforms.

[2] Some co-authors of this article have been participating in such discussions.

Read the original blog post on the BMJ Global Health blog here.

Like South Korea, Thailand, and other countries in the region, Indonesia rolled out foundational provider payment reform with its national health insurance scheme, Jaminan Kesehatan Nasional (JKN). Years of research show that the use of capitation-based payments for primary care is the most cost-effective way to deliver a set of services; thus, Indonesia adopted this into JKN.

This rollout entailed several different types of payment mechanisms focused on maximizing efficiency, reducing moral hazard, and guaranteeing delivery of benefits to Indonesians. Capitation in Indonesia has not only attracted additional enrollees, but it has also limited the overuse of resources and made care more efficient. But this progress is hampered by under-provision of services, referrals to higher-level providers for non-specialist care, and limited success in prioritizing less expensive health promotion and prevention.

To address these ongoing issues, Indonesia has taken a multi-faceted approach. The government has adapted diagnosis-related group (DRG) systems from countries like the United States and Australia and some European nations to fit their local context, needs, and capacities. The government has also pursued performance-based capitation to incentivize fewer unnecessary referrals. Though these initiatives have received mixed results so far, there is a rich trove of lessons to be taken from Indonesia’s experience with blended provider payment systems. And these lessons can be applied to nations across the globe.

In our latest Counterpoint webinar on June 12, we explored the topic of provider payment reforms in Indonesia and future direction with a tight focus on integrated health system reforms.

Watch the recording

In this edition, ThinkWell’s Nida Hameed, a Technical Advisor in Pakistan, hosted a panel of four local experts:

  1. Dr. Hasbullah Thabrany, MPH, DrPH, the Chief of Party for ThinkWell-implemented USAID Health Financing Activity and a leading public health and health financing expert, covered the background and economic concepts behind prospective provider payments within JKN.
  2. Dr. Atik Nurwahyuni, SKM, MKM, a health financing expert at Universitas Indonesia and a leading technical advisor on provider payment reforms and health financing to MOH, presented and discussed the rationale and the process of setting INA-CBG and DRG payments.
  3. Prof. Dr. Ali Gufron Mukti, MSc, PhD, the Director of BPJS-Kesehatan Indonesia, presented IT support, pay-for-performance mechanisms, and recent achievements in provider payment initiatives.
  4. Dr. Ahmad Irsan A. Moeis, SE, ME, the Head of the Center for Health Financing Policy and Decentralization for the Indonesia Ministry of Health, presented how the government set capitation amounts and INA-CBGs to ensure effectiveness and efficiency in JKN payments.

Some questions that were addressed during the webinar include the following:

  1. How has Indonesia effectively integrated different provider payment methods to incentivize high-quality care delivery while controlling costs for different types of providers and facilities?
  2. What are the key system capacities required for continued provider payment reforms and how do these considerations differ across different priority health areas?
  3. What types of incentive structures and ‘experiments’ has Indonesia done to incentivize quality of care and performance? Which have worked?
  4. With the health transformation agenda and shift to an integrated and life cycle-, promotion-, and preventive care-focused health system, what changes will Indonesia need to make to provider payment processes achieve those goals?

Thanks to all who joined. If you missed it, please take a look at the recording here!

Last week, ThinkWell convened a dissemination event on the COVID-19 vaccine delivery costing study in Kampala, Uganda, that was conducted in collaboration with Kampala Capital City Authority (KCCA) and Ndejje University. The event was attended by 60 stakeholders including the World Bank, Uganda Healthcare Federation, representatives from the private sector and health care providers, the Chairperson of the KCCA Public Health Committee among others.
ThinkWell’s Dr. Charlotte Muheki and Cathbert Tumusiime presented the estimated cost of delivering COVID-19 vaccines in Kampala across 2021 taking into consideration public and private health facility ownership and level of care (primary, secondary, or tertiary). The speakers also shed light on how the vaccination campaign was executed in an urban capital.

Dr. Daniel A. Okello, Director of Public Health, and Environment at the Kampala Capital City Authority, thanked the research team for the high level of engagement throughout the study, this was the was the first costing study where KCCA was involved from start to finish, KCCA took full ownership of the study, supporting tool development and piloting, data collection and analysis, and continuously validating results. Dr. Okello recognized the importance of the study in highlighting the dynamics driving resource use in the COVID-19 vaccine rollout, critical for future vaccine planning and programming in Kampala.
The study report comprising the detailed findings will be available in due course; in the meantime, read more about our work in Uganda here:

On December 7, 2023, we explored how the Philippines is reforming its health financing to purchase integrated health services from networks of providers.

Watch the recording

Integration of care is defined by the World Health Organization as a means “to ensure everybody has access to a continuum of care that is responsive, coordinated and in line with people’s needs throughout their life.” Globally, there is much enthusiasm towards integrating care to further health system goals. If based on strong primary care and public health functions, integrated care can contribute to improved access, greater equity and efficiency in service delivery, and better quality of care and user experience, ultimately leading to health gains and client satisfaction.

One intervention towards integrating health services is the formation of service delivery networks or networks of care. Many countries, including China, Singapore, and the United Kingdom, have reorganized service delivery based on networks. How these networks are financed—or how they are situated within the country’s purchasing arrangements to use health financing terminology—is a critical factor determining their success.

The Philippines is one such country that is reforming its health system to ensure the integration of health services. In 2019, the country passed a landmark UHC Law introducing structural and functional changes in health financing, service delivery, and governance. The Law requires provinces and cities—referred to as local government units (LGUs)—to integrate health facilities into health care provider networks (HCPNs). The networks will constitute province- or city-wide health systems (PCWHS), each with a functional governance mechanism through an expanded health board and a referral process. The Law also mandates that PhilHealth payments and other revenue for facilities in an HCPN flow into a Special Health Fund maintained by the PCWHS to encourage this integrated approach. The country is piloting this approach in select implementation sites, which will be assessed in 2025, leading to recommendations for integrating all local health systems.

In this Counterpoint, we talked with key experts from the Philippines about these reforms. We heard about how the process of integration is unfolding, explored the opportunities and challenges of purchasing services from HCPNs, and received insights into how the implementation of these ambitious and far-reaching reforms can be improved. We also discussed lessons from the Philippines’ experience that other LMICs can leverage as they develop and execute strategies to ensure integrated health services.

Pura Angela Co, ThinkWell’s Philippines Country Director, hosted the webinar featuring the following specialists:

  1. Laurentiu Stan, an international development professional and current Chief of Party of USAID’s ReachHealth project, will share their experience in supporting the implementation of service delivery networks in the Philippines.
  2. Eduardo Banzon, a regional health financing expert from the Asian Development Bank, will share his perspective on how the Philippines is purchasing integrated health services compared to other regional experiences.
  3. Leslie Ann Luces, the Provincial Health Officer of Aklan will share opportunities and challenges for LGUs to ensure the delivery of integrated health services.

Some of the questions posed were as follows:

  1. How is the Philippines trying to achieve integrated health services through the financing reforms mandated in the UHC Law?
  2. What are the opportunities and challenges to purchase services from HCPNS with the UHC Law?
  3. What has been the progress in terms of implementing these reforms?
  4. What are the lessons and recommendations for its improved implementation?
  5. What can other countries learn from the Philippine experience?

Date and time: December 7, 2023, 7-8:30 PM Manila time (6:00 AM-ET)

Counterpoint is ThinkWell’s signature series of webinars, which offers a platform for free and frank debate about questions related to health system strengthening. Through these honest discussions, we strive to challenge dominant paradigms and scrutinize new trends to ascertain their merit.

As a partner of the Indonesia Health Economics Association (InaHEA), ThinkWell is excited to showcase its achievements in the last year at the 8th Biennial InaHEA Scientific Meeting. Our USAID Health Financing Activity (HFA) is one of our most influential projects in Indonesia and will be featured in several topic areas.

HFA is a five-year project that provides technical assistance to strengthen local capacity in financial analyses, stakeholder engagement, learning, and decision-making in Indonesia. Our HFA team collaborates with Indonesian leaders and institutions to strengthen health financing and propel Indonesia towards achieving universal health coverage. Our team is participating in eight presentations at the conference covering a vast range of topics; our presentations are detailed below. If you are unable to attend, on the last day of the event, the titles of the presentations will link to the presentation materials.

Anita Damayanti Putri, a Pubic Health Analyst with ThinkWell working on Strengthening Strategic Purchasing for Primary Health Care, will be presenting “Assessing Readiness for Service Delivery Redesign in Indonesia for Emergency Obstetric and Newborn Care Services.” Her presentation will be linked below following the conference.

InaHEA has released a series of potential topics for the meeting that includes demographic transition and economic challenges, non-health-related determinants of health, post-pandemic health issues, health behaviors and financing, and tobacco economics. Find the full list, sub-topics, and more information on the meeting here.

Online participation is available. Please take a look at registration details here.

Sarah Saragih, Firdaus Hafidz, Aditia Nugroho, Agnes Caroline, Adwoa Twum, Laurel Hatt, Cheryl Cashin, Nana Tristiana, Tiara Pakasi, and Hasbullah Thabrany

This study, initiated in 2020, aimed to simulate a pay-for-performance model in tuberculosis (TB) service delivery, with strictand flexible payment scenarios based on guideline adherence, using TB service delivery data in 2019 at one Puskesmas and one clinic in Medan. Recommendations for the government include considering flexible reimbursement standards and conducting additional research on payments to hospitals for referred patients.

Ruli Endepe Al Faizin, Miftakhun Nafisah Yannis Putri, Iko Safika, and Hasbullah Thabrany

The purposes of this study are as follows:

  • To document the prevalence of e-cigarette consumption in Indonesia.
  • To identify the effect of smoking on various groups and poverty levels among households in Indonesia.
  • To compare and contrast the spending on e-cigarette and food consumption  among households in Indonesia.
  • To show the trend of e-cigarette consumption among vulnerable populations (e.g., late teens and young adults).

The research team recommends additional data collection on e-cigarettes and their effects, a higher tobacco tariff on e-cigarettes and a ban on aromatic and flavored e-cigarettes, and a government-led campaign on the health and economic risks of smoking both cigarettes and e-cigarettes.

Rizki Tsalatshita Khair Mahardya, Yudistira Permana, Ririn Ariani Dewi, Putri Listiani, Muhammad Akmal Farouqi, Naufal Mohamad Firdausyan, Astara Lubis, Yosinda Arsy, Inraini Syah, Maria Hotnida, Iko Safika, and Hasbullah Thabrany

This analysis aimed to demonstrate improvements in access and the quality of maternal and newborn health (MNH) services with the new tariff stated in the Minister of Health Decree (Permenkes) No. 3/2023). The decree was on new standard tariffs for health services under the National Health Insurance (JKN) scheme and the implementation of non-payment interventions. The team concluded that continued monitoring of the governance process around MNH services provision would ensure better communication between health providers, local health offices, and BPJSK branch offices and improve MNH outcomes.

Mutia Astrini Pratiwi, Iko Safika, Anita Damayanti, Halimah Mardani, Febriansyah Budi Pratama, Made Anggarawati, Rahmad Asri Ritonga, and Rahma Anindita

Though Ministry of Health Decree No. 64/2016, mandated that JKN tariffs, both at the hospital and primary levels, should be adjusted every two years, the tariff has not been adjusted since its introduction eight years ago. Operating costs continue to increase, so, to promote fairness at primary health care centers (PHC), this team used age and gender as risk factors to calculate a new, risk-adjusted tariff. Ultimately, they recommend that the tariff be regularly evaluated and adjusted, an M&E dashboard should be used to analyze use trends, and another payment mechanism should be determined for PHCs in remote areas.

Mentari Widiastuti, Abigael Wohing Ati, Lambang Wahyu Nugroho, Shita Dewi, Yuli Farianti, Mazda Novi Mukhlisa, Elvina Diah, Iko Safika, Ruli Endepe Al Faizin, and Hasbullah Thabrany

The research question for this study was “how much did the patient pay out of pocket at a facility for the current visit for the following items: registration, laboratory/radiology examination, medical procedures and consultation, medicines, preventive services, and a bed.” Based on responses to this question, the team recommends enhancing the coverage of JKN and reassessing membership types, expanding JKN’s connections with PHCs, and conducting further qualitative studies and data triangulation.

Iko Safika, Yuli Farianti, Ackhmad Afflazir, Hasbullah Thabrany, Sushanty, Sarah Straubinger, and Ritu Kumar

The goal of this study was to examine the challenges and opportunities of improving the capacities of Government of Indonesia, which is HFA’s main counterpart, specifically the Center of Health Financing and Decentralization Policy (Pusjak PDK). The researchers concluded with two recommendations:

  • With the introduction of new laws, organizational changes, and subunits within the establishment, a concentrated effort is needed to foster enhanced analytical skills and understanding of health financing concepts. Additionally, it is essential to develop capacity for creating evidence-based policy briefs that effectively communicate ongoing progress in health financing and information reform initiatives.
  • Continued capacity building can be achieved through on-the-job training, coaching, and mentoring. These strategies will effectively address the high turnover and demanding schedules of staff members, allowing them to participate in training sessions.

Diah Eva Sari Husnul Khotimah, Ruli Endepe Alfaizin, Dini Kurniawati, Mutia Astrini Pratiwi, Iko SafikaNurhalina Afriana, Romauli, Indah Budiarty, Maria Hotnida, Amalia Zulfah Dani Hari WijayaWindi Haryani, Nana Tristiana Indriasari, and Hasbullah Thabrany

This team aimed to calculate the cost of viral load (VL) testing per patient per year, including the cost for specimen transport, at health facilities. They applied unit costs to inform a budget impact analysis and estimate the costs of covering comprehensive HIV services, including VL testing, under JKN. The researchers recommend that further expansive of VL test coverage at the PHC level should be targeted, regional variations of VL testing machines should be considered when determining reimbursement rates for such services, and necessary specimen transport costs should be included in these rates.

Dini Kurniawati, Iko Safika, Hasbullah Thabrany, Ackhmad Afflazir, Tri Indah Budiarty, and Lanny Luhukay

This study was conducted to understand the demographic status of respondents, understand access and adherence to antiretroviral treatment (ARV) among JKN members, and explore factors associated with access and adherence to ARV treatment among members. The researchers recommend health care providers consider implementing multi-month dispensing of ARV to ensure that PLHIV have an adequate supply and offer counseling services aimed at reducing internal stigma and encouraging ARV adherence.

By Nirmala Ravishankar, John Kinuthia, Agnes Gatome Munyua, Boniface Mbuthia, and Anne Musuva

The Facility Improvement Financing (FIF) Bill unveiled by the Government of Kenya in August 2023 is a win for health facilities in the public sector. If passed, the FIF Bill will allow them to directly receive funds and spend them on some operating costs. How big of a win the legislation will be depends on how easy (or complex) it is for facilities to use the funds. The FIF Bill is a step in the right direction, but some of the specifics remain to be fine-tuned.

Devolution and its implications for facility financing arrangements

Kenya shifted to a devolved system of government in 2013. This proved to be a turning point for facility financing arrangements in the country. Prior to 2013, health facilities retained and spent revenue from user fees, health insurance, and other payment schemes. Following devolution, the newly formed county governments asserted control over all revenue in the county.

To substantiate their control, the counties cited the Public Financial Management (PFM) Act of 2012 to require facilities to remit their revenue to a county revenue fund. While the PFM Act does describe this as the default position, it also allows county governments to authorize entities like health facilities to retain their revenue. But many county governments asserted control over all facility revenue, which hampered the latter’s ability to function effectively.

Some counties have tried to rectify the problem using different approaches, resulting in considerable variation in facility financing arrangements across Kenya’s 47 counties. While 10 county governments have passed laws or adopted practices to grant financial autonomy to facilities, 21 counties still claim all facility revenue. In the remaining 16 counties, facilities have access to some of the funds they collect, while the rest goes to the county. Among these 16 counties, 10 have created a central, special purpose “FIF fund” to hold all facility revenue. Through this fund, a county retains a percentage of the funds to cover its administrative costs and transfers the rest back to the facilities; however, county-level structures and processes to administer the fund typically result in a delay in fund flow.

Restoring autonomy to health facilities

The FIF Bill corrects for several things.

  1. First, it states unequivocally that health facilities can retain all revenue they generate in their own accounts, restoring to facilities autonomy that they had before devolution in Kenya. This is especially important for the 21 counties where facilities presently cannot retain any of their revenue. It also rules out the continuation of county-level “FIF funds” to pool facility revenue.
  2. Second, the bill stipulates that facilities can retain any unspent funds at the end of the fiscal year. This prevents county treasuries taking back all unspent funds. Having residual rights over its revenue will hopefully create incentives for a facility to use its funds judiciously.
  3. Third, it does away with the need for each county to pass enabling legislation to grant facilities financial autonomy. Having such laws passed and implemented has proven arduous and time-consuming. Indeed, several counties have enacted laws, but not operationalized them.
  4. Fourth, the bill calls for the integration of facilities into the Government’s financial management information system and routine budget implementation reports. This will give facilities greater legitimacy within Kenya’s PFM architecture and enable greater visibility over facility revenue and expenditure.
  5. Fifth, the bill emphasizes ongoing monitoring of its implementation. In so doing, it sets the stage for greater learning and knowledge-sharing about best practices.

How the bill could be improved

While the bill empowers facilities to retain their revenue, the processes described for them to spend these funds seems unnecessarily bureaucratic. As is standard practice for government entities in Kenya, health facilities must prepare annual budgets for approval by the county government and receive an “authority to incur expenditure” (AIE) from the county government on a quarterly basis to spend their money. But the bill stipulates that, even after receiving AIE, facilities must raise vouchers for approval by the county department of health accountant. Then the subcounty accountant, who is a co-signatory on the facility account along with the facility in charge, must authorize the transaction. The number of steps needed by various government officials for the facility to merely spend funds in its account against its approved budget seems excessive. Moreover, these provisions go beyond what is current practice in many counties, meaning some health facilities will have less flexibility than they presently enjoy.

It is also interesting to note the comparison between the health and education sectors in this area. Schools receive public funds from the national government on account of education not having been devolved. Each school has a management board comprised of officials from the school and community members, which approves its budget. The school in charge is the accounting officer for the school’s accounts and can spend funds as per the school’s approved budget after receiving the quarterly AIE from the county department of education. In contrast, the FIF Bill stipulates that health facility budgets must be approved by the county. The county chief officer for health is the accounting officer for health facilities. And the county health accountant must approve each transaction. In other words, even after the bill, it seems health facilities will have less autonomy than public schools presently enjoy in Kenya.

When it comes to public moneys, authority to spend must be balanced against financial controls. While the FIF Bill reflects this imperative, it seems to err on the side of more rigid control. The process seems especially onerous given that county governments will continue to pay for big expenses (like worker salaries, infrastructure, and most drug costs), while facility funds will pay for relatively small operating costs. The over-prescription of process will erode the very autonomy that the bill aims to establish. Correcting for this—in the implementation regulations if not in the bill itself—will ensure that this important piece of legislation leads to meaningful change.

One month ago, the Government of Kenya released four new health bills to accelerate progress towards the goal of universal health coverage. If passed, the bills will set in motion far-reaching reforms to how health services are financed and delivered in Kenya. Among these bills is the Social Health Insurance Bill, which proposes extending health insurance to all Kenyans based on member contributions, with government-subsidized coverage for the poor. It also mandates the creation of three funds to cover different types of services and a new government agency to manage it all.

To unpack what the Social Health Insurance Bill aims to do, why, and how, ThinkWell hosted a Counterpoint webinar with the bill’s primary architects, county stakeholders, as well as leading health financing experts on October 3, 2023.

Click the button below to watch the webinar recording on our YouTube channel.

Watch the recording

Counterpoint is ThinkWell’s signature series of webinars, which offers a platform for free and frank debate about questions related to health system strengthening. In this edition, ThinkWell’s Regional Director for East and Southern Africa, Dr. Anne Musuva, hosted a discussion about Kenya’s new Social Health Insurance Bill featuring four panelists:

  • Dr. Elizabeth Wangia, Director, Healthcare Financing, Kenya Ministry of Health
  • Dr. Daniel Mwai, President’s Advisor on Health and Standards, Office of the President, Kenya
  • Mr. Felix Murira, Country Program Manager, ThinkWell Kenya
  • Dr. Joy Mugambi, County Director of Health Administration and Planning, Nakuru County, Kenya

Some of the questions the panel explored include the following:

  1. What overarching objectives is the Social Health Insurance Bill trying to achieve?
  2. What drove the specific design choices (e.g., three separate funds, means-testing for everyone not employed in the formal sector, and a new health authority)?
  3. How do the reforms envisioned by this bill align with the service delivery reforms set out in the other bills, especially the reorganization of all primary and secondary care facilities into networks?
  4. What is the role of counties in implementing these reforms?
  5. What are the biggest hurdles we can expect on the way to implementing the bill successfully?

Please contact our team with any questions or concerns.

By Kristan Jela Tambio, Helena Lagon Alvior, Pura Angela Co, Maria Eufemia Yap, Mary Camille Samson, and Rosario Dizon

As the Philippines continues its progress towards fully implementing its Universal Health Care (UHC) Law (RA 11223), it is crucial to harness ground-level insights and best practices that can be shared across the different provinces and municipalities in the country. ThinkWell Philippines and the Asian Development Bank (ADB) recently supported the Department of Health (DOH) Western Visayas Regional Office to organize and facilitate the first regional UHC Summit on July 12, 2023. It was followed by the two-day Learning Forum, which fostered further learning exchange on the progress of the technical, managerial, and financial integration across the province-wide and city-wide health systems in the Western Visayas Region.

The Western Visayas Region is currently the first region in the country where all six provinces and two highly urbanized cities have committed to restructuring their health systems according to the mandates in the law. This ensures that there is a region-wide effort on local health systems integration. In his opening statement, Regional Director Dr. Adriano P. Suba-an said, “Your presence here is a testament that we are on the right track towards the achievement of the UHC with inclusivity, creativity, and purposive expansion of medical coverage and reach.”

The summit was designed to celebrate gains and acknowledge and address the challenges the different local government units have faced during the past three years of implementation. The first panel focused on the accomplishments achieved by individuals within the local health offices and government units. In contrast, the second panel, composed of a different set of local chief executives (LCEs), provincial health officers, and municipal health officers, recounted significant milestones and hurdles on several topics, such as the stewardship of province-wide health systems, comprehensiveness of the primary care package and health care provider networks, human resources for health, and health financing (particularly the special health fund and frontload support mechanisms). The provinces also showcased their achievements in the Key Result Areas of the UHC Local Health Systems Maturity Level via a gallery walk during the event. Summit participants had the chance to ask provincial representatives how they progressed in their Key Result Areas and share their insights and experiences.

Several stakeholders shared key insights and ideas to strengthen the implementation of the UHC Law. Mayor Irene Montilla of Isabela, Negros Occidental advocated for allocating a minimum of 15% of the budget of local government units for health care as a tangible commitment of local chief executives towards health and health equity within the community. Furthermore, she underscored the necessity of working as a cohesive local health system, as the rural health unit cannot operate in isolation. Dr. Leslie Anne Luces-Sedillo of Aklan highlighted the significance of a transdisciplinary approach, the pivotal roles played by organizations like the Association of Municipal Health Officers of the Philippines, the LCE’s ownership of the UHC principles, and the importance of fostering collaboration at the grassroots level. Dr. Luces-Sedillo emphasized the finance team’s indispensable involvement in ensuring the local health care system’s financial sustainability. Dr. Sheila Gumabong of Guimaras reiterated how creating legal instruments fostered trust and collaboration by providing clarity of shared responsibility among key stakeholders such as local health offices, LCEs, hospital and facility heads, and private sector stakeholders.

The speakers also called for improvements and efficiency in the system. Current guidelines in the special health fund sandbox require an escrow or buffer fund to secure frontloading of funds from PhilHealth. This may tie up and render a significant portion of the local government units’ funds unusable especially for provinces with very limited fiscal space, prompting Governor Joaquin Carlos Rahman Nava of the Province of Guimaras to call for a more streamlined and cost-effective way of acquiring and utilizing the frontloaded money in the special health fund.  Additionally, Dr. Maria Socorro Quiñon from Iloilo Province encouraged service providers to place prime importance on their financial sustainability and the integrity of their services by clarifying standards of care at each level, especially the primary care level.

The event ended with a ceremony celebrating the commitments of health teams and stakeholders, such as the local government units, civil society organizations, and non-governmental organizations, to work towards UHC, focusing on essential lessons and implementation advancements. In the words of Regional Director Suba-an, “Indeed, we have shown and proved to the rest of the regions in the country that here in Western Visayas, walang maiiwan (no one gets left behind). In our pursuit of UHC, everyone is on board, and no one will ever be left behind. Padayon kita sa paghugpong agud ang UHC nga handum, aton maagom (Let’s continue to unite so that we can achieve the UHC that we want).”

In the two-day Learning Forum that followed, ThinkWell’s partner provinces, Antique and Guimaras, provided significant contributions on technical and financial integration as they discussed the unification of care pathways design within a province-wide health system and health care provider networks, the development of a referral manual within the care system, analysis of referral form data, setting up the special health fund, and the KONSULTA sandbox experience. ThinkWell and ADB will publish learning from the Learning Forum to provide insights to the DOH and other regions as efforts toward full UHC implementation continue.

We want to extend our deepest gratitude to the following individuals who were also present at the UHC Summit:

  • DOH Western Visayas Regional Office: Dr. Mary Pauline Angelique C. Gestosani, Chief of RLED, and Dr. Mary Joy D. Castroverde, Head of HSIMEC
  • Provincial Health Officers: Dr. Leoncio Abiera, Jr. from Antique Province, and Dr. Ramon Alex Nolasco from Capiz Province
  • Municipal Health Officers: Dr. Christian Earvin Bondoc from Igbaras, Iloilo; Dr. Melba Billones from San Jose, Antique; and Dr. Uldarico Babayen-on, Jr. from Sebaste, Antique
  • Development Partners: ReachHealth and the World Health Organization