Written by Marissa Maggio (Communications Specialist, ThinkWell), Anne Musuva (Country Director, ThinkWell Kenya), and Nirmala Ravishankar (Program Director, ThinkWell)

Kenya’s health system has evolved significantly over the past decade; however, one goal remains unchanged—achieving universal health coverage (UHC), the guarantee that every Kenyan has affordable, equitable access to the highest attainable standard of health. And within Kenya’s commitment to this broader vision, the country has prioritized improving maternal health outcomes. As part of its strategy to achieve this goal, Kenya introduced a free maternity policy in 2013 that discontinued all fees for deliveries at public facilities, helping to remove financial barriers preventing women from accessing skilled, facility-based care during childbirth. Then, in 2017, Kenya’s Ministry of Health (MOH) delegated the implementation of this flagship maternal health policy to the National Hospital Insurance Fund (NHIF) under the renamed Linda Mama program. This program gives women who register with the NHIF access to an expanded package of maternal and newborn health services—free of charge—from NHIF-contracted public and private providers.

A recently published study by KEMRI Wellcome Trust and ThinkWell explores the gaps between the design and implementation of the Linda Mama free maternity program. To discuss the study’s key findings, ThinkWell’s Strengthening Strategic Purchasing for Primary Health Care (SP4PHC) project partnered with KEMRI Wellcome Trust and P4H to host a webinar on November 9, 2021 with experts from across Kenya’s health sector.

Moderated by Dr. Anne Musuva, Country Director of ThinkWell Kenya, the webinar included opening remarks from Mr. Claude Meyer, Coordinator of the P4H Network; presentations from Dr. Isabel Maina, Head of Healthcare Financing at Kenya’s Ministry of Health, and Dr. Edwine Barasa, Nairobi Director of the KEMRI Wellcome Trust Research Program; reflections from Mr. Wambugu Kariuki, Head of Beneficiary Management at the NHIF, Dr. Patrick Kibwana, Chief Officer of Health Services at the County Government of Makueni, and Dr. Wangari Ng’ang’a, Senior Health Advisor at the Presidential Policy and Strategy Unit in the Executive Office of the President; a live discussion led by Dr. Anne Musuva; and closing remarks by Dr. Nirmala Ravishankar, Program Director at ThinkWell.

These experts examined the progress made through Linda Mama and how addressing new challenges can inform the country’s broader UHC reform.

Where is Kenya now?

While Kenya has made strides in recent years to improve access to maternal health services, there is still more progress to be made. To highlight how far Kenya has come, experts discussed the country’s progress following the transfer of the Linda Mama program from the MOH to the NHIF. First, the number of mothers who benefitted from the program has increased, from about 321,000 in 2017-2018 to 784,000 in 2020-2021, according to NHIF data. Second, there was a notable jump in the utilization of institutional deliveries, with the percentage of mothers delivering in public facilities increasing from 44% in 2012/13 to a current rate of 79%, according to statistics tracked by the MOH. Third, the government has increased its allocation to the Linda Mama program, demonstrating the country’s commitment to advancing maternal health.

Lessons Learned

Despite Kenya’s progress, there is still room for improvement. Indeed, findings from the study by KEMRI Wellcome Trust and ThinkWell reveal that the transfer of the Linda Mama program solved for some problems—including expanded coverage and improved operational efficiency—but has introduced new operational challenges. This has caused a disconnect between how the program performs on the ground and its intended design. From the webinar discussion, four main themes emerged:

1. Strengthen communication. There is currently a gap in communication between the NHIF, local governments, providers, and beneficiaries, which has caused inconsistencies in implementation. For instance, eligibility criteria for beneficiaries, as well as which services are covered by Linda Mama, is unclear among many patients and providers. This reduces utilization of the program, since many providers and mothers are unaware of the full suite of services available. To address this challenge, lines of regular communication between policymakers, providers, beneficiaries, and frontline workers must be established.

2. Improve integration. In several counties where Kenya’s UHC scheme was piloted, some health providers were unsure about whether the Linda Mama program was discontinued. This suggests that improved integration—and reduced fragmentation of Kenya’s health schemes—is needed. Improved integration and reduced bureaucracy among parallel health schemes may also help improve the timing and flow of funds between the NHIF and public facilities, helping the NHIF to prevent delays when reimbursing facilities for services rendered. These delays deny facilities resources to improve the quality of their services and, often times, puts the cost back onto patients—contrary to the UHC vision of affordable, accessible health coverage. Conversely, encouraging integration will ensure that Linda Mama benefits are preserved, expanded, and complimentary to Kenya’s scale-up of its UHC scheme

3. Adopt a whole systems approach. Beyond health care financing, health reforms should also consider other inputs, processes, and financial barriers that may prevent mothers and newborns from accessing the care they need. For example, because some public facilities lacked access to essential medicines, patients had to pay out-of-pocket or go elsewhere to find commodities that should be free and readily available. And for those who do not live near a health facility, distance can serve as an additional barrier to access by introducing extra costs for transportation. Moreover, benefits packages should be informed by Kenya’s health needs. Currently, some key services are excluded from the Linda Mama benefits package, including coverage for ultrasounds and family planning as part of postnatal care, despite a demonstrated need for these benefits. To address these shortcomings, Linda Mama’s scope of benefits should be expanded and diverse socioeconomic needs—beyond child delivery and postnatal care—should be considered to improve health outcomes for the mother, baby, and entire household.

4. Promote evidence and learning. The NHIF should continually monitor and promote sharing of the latest evidence and learning. By tracking which facilities are staying true to the free maternity policy design and encouraging inter-county dialogue, this may enable the NHIF to move beyond its primary role as a payer to become a strategic purchaser that helps shape the health sector, the behavior of providers, and the success of the Linda Mama program.

Experts remarked at the undeniable progress that Kenya has made through the Linda Mama program to ensure better access to maternal health services. For instance, in Makueni County, the removal of user fees has contributed to a decreased poverty rate and increased quality of care, with more facilities better equipped to manage maternal complications. However, the evaluation conducted by KEMRI Wellcome Trust and ThinkWell has shown that the implementation of the Linda Mama program must continue to improve. To date, Linda Mama is the only universal entitlement program in Kenya available to every mother, regardless of their location and income status. Over time, the Linda Mama program aims to integrate under the national UHC scheme. As Kenya moves towards this goal, the country must ensure that mothers and newborns receive the benefits they need to thrive.

If you want to learn more about ThinkWell’s work in strategic purchasing for primary health care, you can read about it here. You may also watch the full webinar recording below.

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This piece originally appeared in P4H here.

Written by Angela Kairu (Research Officer, KEMRI Wellcome Trust), Marissa Maggio (Communications Specialist, ThinkWell), Nirmala Ravishankar (Program Director, ThinkWell) and Edwine Barasa (Director, KEMRI Wellcome Trust).

Public sector health care facilities are a major avenue for the delivery of key health interventions in many low- and middle-income countries (LMICs) and, as such, how they are financed is critical for determining their performance for serving communities. As Kenya forges a path towards the goal of universal health coverage (UHC)—a vision whereby all people can receive first-rate health services without suffering financial hardship—health facility financing mechanisms in the public sector must be strengthened to ensure equitable access to care, while also safeguarding individuals from burdensome out-of-pocket costs.

The COVID-19 pandemic has further underscored the importance of ensuring that resources flow smoothly and rapidly to frontline providers, enabling them to respond appropriately to unprecedented health crises. As Kenya works to enhance health system resilience, improving financing arrangements for public sector health facilities has emerged as an urgent priority.

Facility financing in Kenya underwent a dramatic change in 2013, when Kenya transition to a devolved system of government. While the national government retained the function of policy-making and regulatory oversight, responsibility for service delivery was shifted to 47 newly formed county governments. Simultaneously, user fees in public health centers and dispensaries were abolished, and the national government established a mechanism to reimburse facilities for lost revenue via conditional grants to the counties. How those funds are managed is up to the county. Consequently, anecdotal evidence points to significant variation across counties in facility financing arrangements.

In a newly published study, KEMRI Wellcome Trust and ThinkWell report findings from an assessment of resource flows to public health facilities in five counties. The study provides critical insights for public finance management (PFM) practices and health financing arrangements in Kenya, as well as lessons for other LMICs exploring ways to enable direct facility financing.

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Written by Pura Angela Wee-Co (Country Manager, ThinkWell), Ileana Vilcu (Program Manager, ThinkWell), and Marissa Maggio (Communications Specialist, ThinkWell)

The COVID-19 pandemic has stifled nations across the globe in their pursuit for Universal Health Care (UHC)—and the countries that make up the Association of Southeast Asian Nations (ASEAN) are no exception. For many, the pandemic has introduced additional barriers to high-quality health care at a low cost. To highlight how ASEAN nations are rising to new challenges, the Center for Strategic and International Studies (CSIS) held a webinar in August 2021 to discuss a path towards sustainable health care financing in the region. Joined by other experts, Dr. Marife C. Yap, Senior Technical Advisor at ThinkWell Philippines, discussed how the country has responded to COVID-19 challenges and several strategies that national health systems can employ to make UHC a reality.

Following the passage of the Universal Health Care Act in 2019, the Philippine Health Insurance Corporation (PhilHealth) was tasked with putting the law into practice and launched KonSulTa, a primary care benefits package that provides access to comprehensive outpatient services under one affordable, fixed rate. However, with multiple lockdowns, widespread mobility restrictions, and a reduced budget, PhilHealth has faced several challenges in ensuring equal access to care. For instance, PhilHealth experienced hurdles in quickly and sufficiently reimbursing coverage payments—such as those for COVID-19 testing—to hospitals, which limited the delivery of essential health services.

Faced with these new obstacles, what can the Philippines do to improve UHC? Dr. Yap touched on several key approaches, including:

1. Integrate across the health system. The key to making the UHC rollout successful, Dr. Yap says, is three types of integration—managerial, clinical, and financial; managerial to ensure capable province-wide health systems, clinical to provide a comprehensive set of health services from preventative to curative, and financial to lessen the fragmentation of fund pools. By ensuring integration across the health system, PhilHealth can establish a smooth delivery of health services under province-wide networks.
2. Simplify membership. Prior to the 2019 UHC law, there were five categories of PhilHealth membership, which led to confusion and limited enrollment. Now, membership has been simplified to just two categories, direct and indirect contributors, which is envisioned to help increase enrollment and access to a universal primary care benefits scheme.
3. Increase and consolidate health funding. Despite increased health budgets during the COVID-19 pandemic, the Philippine Department of Health (DOH) has only disbursed 141 billion pesos out of the 205 billion allocated to tackle diverse health needs. To achieve UHC, the DOH needs to remain accountable for the proper allocation of funds and continuously demonstrate the value of maintaining a substantial health budget. This will help the DOH and PhilHealth to improve health service delivery to all Filipinos.
4. Promote utilization. Some health packages offered in the Philippines have experienced low utilization due to a lack of awareness or trust in government agencies. For instance, PhilHealth has offered the ‘Z benefits package’ since 2014, which aims to support health programs that require costly treatments—such as cancer care—and may be delivered through outpatient services. However, despite the support available, a 2020 study shows that the Z benefits package was not widely used, suggesting that awareness must be raised to improve program utilization.
5. Close gaps in coverage. There are several policy gaps that need to be addressed in order to achieve UHC. Foremost among these is the need to change people’s perspective on accessing PhilHealth benefit packages. Because PhilHealth provided mostly inpatient services—or when people are admitted to a hospital—prior to the 2019 UHC law, many are still not aware that more outpatient services are available to them, particularly KonSulTa’s comprehensive outpatient benefit package. This further exacerbates gaps in coverage. In addition, PhilHealth can improve the capacity of health care purchasers to finance both COVID-19 and non-COVID-19 services. Not all hospitals are accredited by PhilHealth, leaving many patients that seek care to pay out-of-pocket for health services. And while there has been a slight decrease in paid claims in 2020, down from those received in 2019, there are still many unpaid claims that must be settled. To provide a comprehensive set of services under UHC, strategic health care financing can close these gaps and ensure costs are covered.

Looking to the rest of the ASEAN region, other panelists touched on several core ideas to improve the sustainability of health care financing during and beyond the COVID-19 pandemic, including:

1. Build awareness. COVID-19 has introduced a unique opportunity to promote awareness of the need for UHC. Although UHC is meant to ongoingly provide essential health services, this pandemic has shown that people need affordable, effective health coverage most in times of crisis. Therefore, this is the best time to hold ASEAN governments accountable to bolster UHC programs and prepare for future emergencies. Moreover, the pandemic response has also lent many lessons that can inform new processes and innovations across health systems. For example, community health workers (CHWs) in the Philippines are not considered part of the official health system. However, the COVID-19 response has revealed the monumental role that CHWs play in managing local, frontline emergency response teams, clearing a permanent space for them in the Philippine health sector.
2. Encourage better health behavior. In addition to addressing pandemic and disease-related challenges, ASEAN governments should seek to promote better health behavior, all the way from health prevention and screening to rehabilitation. For instance, governments can encourage healthy behavior—such as routine immunization—and discourage high-risk behavior—such as high tobacco or alcohol consumption—to keep health costs low and balance the availability of funding across the entire health system.
3. Invest in better treatment. As COVID-19 becomes endemic, or a routine disease found globally at a reduced rate, ASEAN nations must continue to invest in better health solutions that will last beyond the current pandemic. Governments must work towards UHC while accepting that the COVID-19 disease will remain, in some capacity, and continue to innovate better health technologies to improve quality of life for all.

If you want to learn more about ThinkWell’s work in the Philippines, you can read about it here. You may also watch the full webinar recording below.

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This piece originally appeared in P4H here.

Written by Shamima Akhter, Anooj Pattnaik, Callum Pierce, Afroja Yesmin, and Pak Trihono

In the early days of the COVID-19 pandemic, Dr. Helal, the manager of a busy health facility in Bangladesh’s sprawling capital city of Dhaka was faced with an unexpected challenge: how would he pay for the hand gel and masks that were needed to keep his staff and patients safe? “The list of things I needed to pay for grew rapidly,” says Dr. Helal, “the Government acted quickly to mobilize money to my facility but to access that money I had to send dozens of forms and make several trips to the local admin office. Anytime my request changed, the process started all over again.” Like Dr. Helal, front-line responders around the world faced similar challenges in accessing and spending the money allocated to them for COVID-19. To understand why, we need to dive into the world of public financial management, or ‘PFM’.

PFM refers to the laws, regulations, and systems that govern how public funds are allocated, spent, and accounted for, including in and by the health system. In theory, a good PFM system ensures that money gets to where it is needed and is only spent on its intended purpose. In practice, however, PFM rules can be complex and hard to navigate, particularly for health managers from clinical backgrounds with limited training in administration and finance. When it works well, PFM directly supports the attainment of Universal Health Coverage (UHC) because it minimizes waste, directs resources to areas of greatest impact, and maximizes the value for money spent on health. The efficiency of good PFM is particularly valuable in settings where government spending on health is relatively low. In this blog, we shine a spotlight on some of the most important PFM barriers that front-line responders faced when responding to COVID-19. These insights draw from the experience of Bangladesh and Indonesia, where the authors have been working closely with the government to identify and address some of these “plumbing” challenges.

Indonesia is an upper-middle-income country with a decentralized health system and the world’s largest national health insurance scheme, Jaminan Kesehatan Nasional (JKN). Still, the national and subnational governments play a substantial role in financing health providers in the public sector, even as both public and private facilities receive payments under JKN.  Since Indonesia decentralized its health authority in the early 2000s, District Health Office (DHO) priorities do not always match the national ones, and PFM capacities vary across the districts.

When COVID-19 struck in March 2020, Indonesia’s Government mobilized significant resources for the response, including reallocating money away from other front-line services. However, the lack of PFM capacity at the district level to revise budgets according to national government guidelines led to pools of funds for COVID-19 sitting at the national level. Moreover, the central ministries in charge of essential health services (EHS) like family planning (FP), maternal, new-born, and child health (MNCH), immunizations, and nutrition delayed issuing budget revision guidance (and even when they did, they revised it five times) to DHOs and frontline providers, leading to confusion on how to balance COVID-19 services with routine EHS ones. With a lack of funding and guidance flowing from the central and district levels, most frontline providers were left to manage their responses on their own. Those who had special autonomy status, known as BLUD, were able to flexibly use JKN capitation funds in their emergency and routine EHS provision. However, only 20% of over 10,000 public PHC facilities have BLUD status and thus, often did not have the funds at hand to respond in the way they needed to.

This resulted in a chaotic response at the frontline, with each provider charting their own course, and contributed to a large decline in EHS service use with slow recovery. For instance, basic immunization services reduced considerably in 2020 compared to 2019. The largest dip in coverage between the two years was in May (34.5%) and remained at least 20% lower than the previous year’s level until November 2020 where the coverage difference between the two years reduced to 13.9%.

Bangladesh has an extensive primary health care system, supporting the delivery of “good health at low cost.” Resources for the health sector run through the PFM system and has a standard set of rules for all budget planning, execution, and procurement. Though PFM rules give health managers some autonomy over how budgets are spent, decision-making is largely centralized. PFM in the health system is characterized by complexity, with fragmented funding flows and diversity of financing agents at each level of the health system.

When the COVID-19 pandemic struck in Bangladesh, the Ministry of Health and Family Welfare (MOHFW) explicitly set out to conserve funding for essential health services while ramping up spending on the pandemic response. In support of this goal, the Government launched a large economic stimulus package which included hundreds of millions of dollars of additional financing for the health sector. In addition to overall increases in funding, the MOHFW authorized facilities to reallocate some of their unspent budgets toward COVID-19 related activities and issued detailed technical guidance to facilities on how to reconfigure services in a way that would balance the pressure of COVID-19 response with routine service delivery.

Although the Government acted quickly to authorize funding reallocations, health managers faced many barriers in accessing this money for service delivery as they could not follow the PFM process requirement needed for the additional funding. If a manager wanted to use the funds to purchase essential commodities, procedures to comply with the current MOHFW “delegation of financial authority” rules, hindered rapid approval and utilization of funds. For health managers, this represented hours of time they could ill-afford in a crisis. It also meant that the Central Government needed to review hundreds of procurements plans from facilities across the country, which presented a formidable administrative burden. Additionally, because of years of centralized control of financing functions, many health managers did not have the training nor expertise to navigate the complex PFM requirements and unlock the funding available to their facility. Most health managers were largely unaware of the increased procurement flexibility attached to the reallocation of funds for the COVID-19 pandemic.

These pre-existing challenges further contributed to the severe disruption of essential health services delivery in Bangladesh during the early months of the pandemic. For instance, antenatal care visits declined by 34% in April 2020 compared to the previous year, with a gradual and uneven trend toward recovery in the period since.

Written by Andrea Bare (Program Director, ThinkWell) and Martha Coe (Program Manager, ThinkWell)

Routine immunization is not clearly and consistently prioritized—nor is it sufficiently funded—in many countries across the income spectrum. Yet, the evidence has spoken: the benefits of immunization are undeniable. Not only is immunization successful in warding off disease—it is also a cost-effective health intervention. Economic and scientific studies continue to sing the praises of immunization’s value for preventing disease, however, this strong evidence base is not consistently reflected in health policies and budgets.

On September 15, 2021, ThinkWell convened the second event in its Counterpoint webinar series, where four experts were invited to discuss why routine immunization programs struggle to obtain sufficient and sustained funding, and how health advocates may respond to this challenge. Moderated by Margaret Cornelius, Deputy Director of the Private Sector Team at ThinkWell, the four panelists included Eduardo Banzon, Principal Health Specialist at the Asian Development Bank; Ulla Kou Griffiths, Senior Advisor on Immunization Financing at UNICEF and Honorary Associate Professor at the London School of Hygiene & Tropical Medicine; Catherine Goode, Founder of Goode Strategies; and Stefan Swartling, Professor of Global Transformations for Health at the Karolinska Institute. Each provided their unique perspective and expert recommendations on how to elevate financing for routine immunization, including:

1. Tell the full story of vaccination success to generate societal and political demand.
2. Create and maintain a shared agenda across the health advocacy spectrum.
3. Articulate the shared needs of the products, systems, and people involved in immunization.
4. Integrate immunization into primary health care.

1. Tell the full story of vaccination success to generate societal and political demand.

The irony is that when vaccination programs are successful, decision makers and the public can take these programs for granted. Instead, a negative press story, such as a gravely ill person in an intensive care unit, gets far more attention than the thousands of individuals who are safe and well because of vaccination. We must be careful not to become victims of our own success.

To champion routine immunization in the long term, advocates and immunization program managers need to provide ministers of health and finance a clear picture of what their countries would be facing without immunization programs. Providing preventive health care is often thankless, and for people to recognize the value of that investment, advocates must continually communicate the value of successful programs and the broad societal and economic benefits that they bring. There is an opportunity during the COVID-19 response to showcase how immunization programs are rising to the challenge of rolling out COVID-19 vaccines while also highlighting investment gaps, ensuring that both the public and policymakers appreciate the risks to population health if routine vaccinations do not continue—or if we do not prepare for future risks.

2. Create and maintain a shared agenda across the health advocacy spectrum.

 Advocates should start with, and come back to, what we have in common. Highlighting the reality that public health priorities compete for scarce resources, panelists emphasized the importance of stepping out of program and funding silos to find common ground. The different programs that make up primary health care, including immunizations, can align under a common agenda to increase broader primary health care funding, thus extending budget benefits across the entire system. Investments that have wider impact are more likely to gain the ears of those who hold the purse strings. As global policymakers come together to discuss funding for pandemic recovery and preparedness, advocates who call for a unified investment in comprehensive primary health care programs will make a stronger case for ongoing immunization funding.

3. Articulate the shared needs of the products, systems, and people involved in immunization.

Broad based investment in immunization involves three components to increase access and uptake: the vaccines, the vaccine delivery system, and vaccine education. Health advocates can better communicate why additional investment is essential by emphasizing the shared needs of the vaccines, systems, and people that sustain immunization programs.

• Vaccines: Sufficient investment is necessary to ensure that vaccine production capacity can meet both regular and peak demand when needed. Manufacturers make these investments when there is a clear signal of demand and financing for immunization programs from the market. The gap in ability to enable surge capacity to meet demand became abundantly apparent during the global COVID-19 pandemic, when countries experienced an urgent need for vaccine supply, along with the equipment and associated medicines required to treat COVID-19 patients. Although procurement models that can support more resilient manufacturing capacity come at a higher cost, investing sufficiently in immunization pays off. For instance, organizations such as UNICEF have shown that creating a healthy vaccine market can help bring in high-quality manufacturers that are prepared to meet vaccine needs.

• Systems: The global health care system and workforce have risen to the challenge of quickly and effectively administering available vaccines. Despite quick adjustments by health systems, the pandemic has revealed capacity challenges for delivering both routine and COVID-19 vaccines. The hurdles that vaccine delivery systems have experienced—such as limited points of access or outdated data systems—are often embedded in primary health care delivery and thus have negative effects that extend beyond immunization. Therefore, investments in vaccine delivery systems must be considered essential not only for effective immunization programs, but also for the overall well-being of a resilient primary health care system.

• People: Ultimately, people are at the heart of health. People drive vaccination demand, and without this demand, prioritization of immunization will be limited. Investments must be made to consistently nurture the value of routine immunization through frequent education and communication, thereby building confidence and cultivating societal demand for impactful vaccination programs.

4. Integrate immunization into primary health care.

Immunization financing must be considered within the broader context. Panelists agreed that primary health care budgets are generally insufficient, meaning that immunization budgets are likewise left scant. The panel discussed the need to better highlight what primary health care is composed of to ensure that immunization is considered central to strong primary health care systems—including vaccinations for children, adolescents, and adults. Additionally, panelists noted that by evaluating other well-funded areas across the primary health care system, advocates can identify opportunities for cost savings and efficiencies. The traditional operating model, particularly for countries that have leveraged donor funding for immunization or other primary health care services, such as HIV or tuberculosis, is to have siloed program funding. However, vaccination services benefit from the investment of other budget lines, including health infrastructure and clinic staff. Maintaining these siloes may harm access to prevention services or primary health care in the long run. Instead, promoting an integrated health delivery approach—which includes vaccination alongside routine primary health care—could provide new opportunities to bolster immunization programs that are prepared to treat a variety of diseases.

If you want to learn more about ThinkWell’s work in sustainable immunization financing, you can read about it here. You may also watch the full webinar recording below.

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.