Summary

Cancer is now the second most common cause of death in high income countries (HIC) and is a rapidly growing concern in low and middle-income countries (LMIC). To shape and inform the policy dialogue around public financing for countries’ efforts to improve cancer control, ThinkWell conducted a landscape review on how health systems can more sustainably and equitably leverage public sector resources to provide comprehensive and high-quality oncology care, including access to new technologies and therapies. This review resulted in six country studies and a global summary. These six country studies draw on the expertise of country health system experts and local stakeholders, bringing together new evidence and fresh perspectives on the state of oncology financing from experience around the globe.

This project is supported with funding from Merck & Co., Inc.

Challenges

Cancer is a growing contributor to the disease burden globally, with cases projected to increase as populations age and average life expectancy increases. In HIC, the “silver tsunami of cancer,” a phrase coined by researchers in the United States, is a poignant metaphor for the challenges that many health systems will face in terms of managing higher caseloads and the health needs of survivors, many of whom will have co-morbidities, making their care both more complex and costly. In LMIC, and even in some HIC, access to care and treatment are often highly determined by a patient’s wealth or place of residence, leading to significant disparities in access and cancer outcomes. Countries of all income levels grapple with how to finance access to new and innovative – and often expensive – cancer therapies while ensuring sufficient funding for prevention programs, integrated care models, and palliative/rehabilitative care.

The oncology continuum is complex, involving a wide set of public sector actors, all of whom directly or indirectly influence the patient experience. From targeted prevention strategies focusing on high-risk behaviors, to targeted therapies by cancer type, public financing and the flow of funds for oncology influence how effectively, efficiently, and equitably cancer interventions reach patients in need or populations at risk. On the one hand, many low-cost, high-impact public health measures to prevent cancer are underutilized and underfunded, while on the other hand, new breakthroughs in cancer therapies are extending survival and quality of life, both during and post-treatment.

Approach

To better understand how countries finance the oncology continuum, ThinkWell, with on-the-ground support from local health financing and health system research experts, analyzed how public funding influences the performance of the oncology continuum from prevention, diagnosis, and treatment to palliative care and rehabilitation.

In reviewing current evidence and gathering insights from local experts and key stakeholders, we aimed to identify the various financing drivers influencing a country’s oncology continuum program, and develop policy options that can help to overcome the financing challenges in the system. We analyzed trends in public funding for cancer and when possible, estimated public cancer expenditures to understand the breadth and depth of public investment in oncology.

This oncology financing landscape resulted in six country profiles that showcase how countries are confronting health system challenges in oncology and what more can be done in the oncology policy and financing environment to increase access and improve cancer outcomes.

Breaking New Ground

This project is unique as it presents a comprehensive review of sustainable health financing from an oncology perspective. The project moves beyond the understanding of current situations at the micro-level to a synthesis of key factors on the macro-level, such as the state of the health financing in general, and how public financing impacts the oncology care continuum.

Summary

To inform world leaders at the G20 Summit in November 2020, ThinkWell assessed innovative finance in health in low- and middle-income countries (LMIC). With funding from the French Ministry of Europe and Foreign Affairs, we mapped the innovative finance initiatives deployed since 2000, including catalytic funds, conditional funds, impact investment funds, and socially responsible investing. In addition, we reviewed 42 major innovative financing initiatives that focus on Sustainable Development Goal (SDG) 3: health and well-being.

Our research’s aim was for the G20’s health and finance ministers, donors, development finance institutions (DFIs), investors, and bankers to not only scale up proven innovative financing for health approaches, but also to take more risks in their investment decisions. In addition, our review’s results were designed to inform G20 leaders about how to direct additional financing and attention to initiatives that have demonstrated impact and replicability. In our report, we presented ways that innovative financing for health could be made more innovative by crowding in new funding, especially from the private sector.

This was the first time since 2011 that a comprehensive, major review of innovative finance for health has been conducted. Our mapping highlights significant new initiatives created in the past decade to help address global development challenges.

Read more about our research in a blog. The Ministry of Europe and Foreign Affairs published our report here and the Leading Group on Innovative Financing for Development published our report here.

Breaking New Ground

In 2015, the UN General Assembly adopted 17 sustainable development goals (SDGs) to end global poverty by improving health, increasing economic growth, and reducing inequality by 2030. SDG 3 specifically aims to “ensure healthy lives and promote well-being for all.” It sets ambitious targets to improve many aspects of health, including reproductive, maternal, newborn, and child health; communicable and noncommunicable diseases; mental health; environmental risks; and health systems strengthening. We mapped 42 major innovative finance initiatives that address SDG 3. In our report, we summarize their successes and learnings so donors and development financing institutions (DFIs) can enhance their use of innovative finance moving forward.

Challenges

The annual funding gap to achieve SDG 3 is estimated at US$371 billion for low- and middle-income countries (LMICs). There are also rising opportunity costs in delaying funding for SDG 3. Ongoing SDG 3 funding delays leads to higher annual costs and lives lost. Delays also imply that health pressures continue to mount, compounding the adverse effects.

Ensuring that SDG 3’s targets are met requires that the social determinates of health and related SDGs be reviewed. There is therefore an urgent need for health leaders to generate and deploy more effective official development assistance (ODA) and other financing, including from the private sector, for SDG 3 and related areas. Innovative finance is one critical approach to undertake this.

Innovative finance can help accelerate the participation of private investors in health and drive more capital into the health sector. In our report, we identify mechanisms and initiatives that have generated additional development funds by tapping new funding sources from the public sector, incentivizing the flow of private sector contributions, enhancing the overall efficiency of financial flows, and facilitating more results-oriented expenditure.

Approach

In our report, we mapped the initiatives and mechanisms across five classifications of innovative financing outlined in our conceptual framework (Figure A):

• Results-based financing
• Catalytic funding
• Impact investing
• Socially responsible investing
• New channels of international and domestic taxation for development

For the outcomes analysis and to formulate recommendations, we adapted four criteria from the Organization for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC): relevance and coherence, effectiveness and efficiency, impact, and sustainability.

Results

We developed four recommendations for how the field of global health can progress most effectively:

1. Innovative financing initiatives must be co-created and designed to be fully compatible with local health markets.
2. The cost of entry to invest in SDG 3 in frontier markets is often perceived as too high by the private sector. Donors and DFIs can address this by scaling up funding that builds an investment pipeline and “crowding in” private sector investment.
3. More transparency and alignment of metrics across all innovative financing mechanisms in health is urgently needed to improve financial and health impact.
4. Innovative finance offers a significant opportunity to fill the SDG 3 funding gap in a sustainable way, but the differences in the relative strengths and weaknesses of the mechanisms should be considered by donors and DFIs during design and then taken to scale.

Summary

MOMENTUM Private Healthcare Delivery (MPHD) is a five-year (2020-2025) global award that seeks to strengthen private provider contributions to maternal, newborn and child health services, voluntary family planning, and reproductive health care (MNCH/FP/RH). The project supports private providers and expands public and private partnerships to strengthen MNCH/FP/RH care.

MPHD is one of a suite of USAID projects that accelerates reductions in maternal, newborn, and child mortality and morbidity in high-burden countries. To do this, the project increases host country commitment and capacity to provide high-quality, integrated health care. MPHD is at heart a “service delivery” program with an emphasis on supply through the mechanism of private providers. At the same time, MPHD recognizes that demand and enabling environment are critically important elements to expanded and sustained health coverage.

ThinkWell is a partner of a global consortium led by Population Services International (PSI), with partners Jhpiego, Avenir Health, and FHI 360. ThinkWell serves as the technical lead on health financing for sustainability of private sector service delivery.

Challenges

Over recent decades, incredible progress has been made to improve outcomes for maternal, newborn, and child health. From 1990 to 2015, the global maternal mortality ratio declined by 44%, with some of the most significant gains coming from RMNCH priority countries. In 2017, global coverage rates for diphtheria-tetanus-pertussis (DTP3) reached 85%, up from 21% in 1980.Globally, use of modern contraception has risen slightly, from 54% in 1990 to 57.4% in 2015.In 2018, there were 48 million additional FP users compared to 2012.

Despite these gains, more remains to be done to ensure that quality MNCH/FP/RH services are provided at scale and sustainably. To advance health systems strengthening across low- and middle-income countries (LMICs), donors make large investments to increase the capacity and knowledge of providers. Donors also make large investments to improve the regulatory and policy environment and alignment of incentives across stakeholders. Yet these efforts focus primarily on public-sector facilities and providers. There are few documented large-scale attempts for comprehensive market systems strengthening across the private sector, including supply chain, provider capacity and motivation, and the creation of a favorable financing context for private providers. In some limited cases, governments have used strategic financing mechanisms to address the challenges of capacity, quality, and motivation seen in the private health care sector. Governments have not systematically leveraged financing mechanisms to improve private-sector MNCH/FP/RH service delivery. Private MNCH/FP/RH providers face unique challenges which undermine their ability to achieve quality at scale and sustainably to meet population health needs.

Approach

ThinkWell strengthens private provider engagement with governments through 1) facilitating private provider engagement with purchasing and 2) improving the coherence of quality schemes.

MPHD has four overarching technical priorities to increase availability of and demand for quality MNCH/FP/RH information, services, and supplies offered by private providers and expanded public and private partnerships. This will help to ensure a total market approach (TMA) for improved health coverage. These technical priorities encompass how MPHD delivers the overarching MOMENTUM suite of improved MNCH/FP/RH care. MPHD’s specific priorities reflect important contributions to market-based solutions that support countries’ Journey to Self-Reliance.

Figure 1. MPHD Key Technical Approaches

Summary

With support from the World Health Organization (WHO), ThinkWell conducted a six-part webinar series from May to November 2019 on how to ensure that public financial management (PFM) provides an enabling environment for sustainable health financing policies. Webinar topics included budget formulation issues, budget execution issues, links between budget reforms and provider payment systems, budget accountability, and budgeting in devolved settings. The series aimed to enhance technical knowledge and capacity among health sector stakeholders and stimulate peer exchange on the implementation of budget reforms in health. To learn please visit the WHO’s page on the series here. The webinar recordings have been converted into 30-minute video podcasts that can be accessed here.

Session 1: Role of PFM functions and reforms from a health sector perspective

Many countries place public funds at the core of health financing to progress towards universal health coverage (UHC). A strong PFM system is key for sustainable financing for UHC, and as a result, many countries have initiated long-term PFM reforms. In this session, we discussed the importance of compulsory public funding for UHC and the main PFM challenges in the health sector. We provided examples of successful PFM reforms in African countries to illustrate points.

Session 2: Budget formulation issues in the health sector: key issues for policy makers

An increasing number of countries recognize that budget formulation influences health sector spending and performance. Countries have modified the way that budgets are formulated to ensure better alignment of sector priorities. This session provided an overview of budget formulation issues in the health sector and reforms from OECD countries. As case study examples, we presented key insights on budget formulation and dived into South Africa’s program structure.

Session 3: Budget execution issues in the health sector: challenges and policy responses

Budget execution poses many challenges in the health sector in several low and middle-income countries (LMICs). One of the main challenges in LMICs are underspent health budgets. In this session, we discussed the role of budget execution in the health sector. We also provided an overview of budget execution in LMICs, with a focus on Mozambique.

Session 4: Links between budget reforms and provider payment systems: what is at stake?

The way public budgets are formed, allocated, disbursed, and accounted influences how service providers are paid in the health sector. In this session, we focused on how to align autonomy, incentives and objectives as well as budget classifications and their links with provider payment methods.

Session 5: Budget accountability: financial transparency and accountability towards sector outputs

Comprehensive information about public finance needs to be publicly accessible so governments can be held accountable and to promote an informed dialogue around policy priorities. Health spending is typically characterized by poor transparency and accountability. In this session, we focused on the road to budget transparency and accountability in health, the role of government-civil society collaboration in improving budget accountability, and performance frameworks for program budgets.

Session 6: Budgeting for health in devolved settings

The budgeting process in devolved settings can prove to be very complex, particularly in the context of weak governance systems. In this session, we discussed implications of fiscal decentralization for the health sector and we shared country experiences from Argentina and Kenya.

In partnership with Rockefeller Foundation, ThinkWell provided catalyzing support to facilitate the development of a network of African institutions to improve the uptake of health systems and policy research in policymaking and practice. ThinkWell mapped the terrain of institutions and networks engaged in health research, analyzed their capacities, identified gaps and opportunities, and created a pan-African steering committee to address the evidence-to-policy gap. The steering group brought together academic institutions, government bodies, regional economic communities, civil society organizations, and the African Union. At the end of one year, ThinkWell successfully transitioned leadership to five core African partners.

The Health Workforce for the 21st Century (HW21) Program supports high HIV burden countries to meet UNAIDS’ 90-90-90 goals. The program works with PEPFAR countries to build competent and confident allied health professionals and effectively employ, deploy, and retain a workforce that delivers high-quality, HIV care where these services are most needed.

ThinkWell was a member of the HW21 consortium of partners coordinated by Jhpiego. ThinkWell provided analysis, technical support, analytical assessments and policy advice in areas including, but not limited to, the transition of PEPFAR-funded health workers to the health system, health labor market analysis to leverage a deeper understanding of what influences the demand and supply of health workers, and identification of solutions to strengthen process for deployment and retention of health workers.

Summary

In 2012, with support from the Rockefeller Foundation, ThinkWell aimed to strengthen the use of health policy and systems research (HPSR) in the policymaking process—with a geographic focus on sub-Saharan Africa. First, we mapped the sub-Saharan African institutions and networks engaged in health policy and systems research, analyzed their capacities, and identified gaps and opportunities. We then convened key partners, including health policy and systems researchers, government stakeholders, and development partners, for a three-day consultative meeting at the Rockefeller Center in Bellagio, Italy. During the meeting, we facilitated a discussion on how to create a sub-Saharan African network that promotes health policy and systems research for policymaking purposes. Finally, we presented an investment case to the Rockefeller Foundation.

Challenges

The health policy and systems research landscape in sub-Saharan Africa has changed dramatically in recent decades. There are a growing number of African institutions engaged in HPSR. In addition, government bodies increasingly facilitate high-level discussions on health systems and policy issues. These institutions and initiatives have enriched the evidence-base for health systems reforms and have fostered dialogue and debate on health policy issues in sub-Saharan Africa. Despite the progress, there is poor integration and under-use of HPSR in policymaking processes. In addition, sub-Saharan African capacity for health system and policy research is low.

Approach

ThinkWell completed a desk review and a landscaping analysis to identify African institutions that are actively engaged in HPSR. We then organized a three-day consultative meeting at the Rockefeller Center in Bellagio, Italy to present our findings and to guide discussions on how to improve health policy and systems research. The meeting’s aim was to create a model for a network of sub-Saharan African health systems and policy research institutions to boost knowledge creation for policy uptake. During the meeting, we arrived at a vision for a network of sub-Saharan African institutions and networks that would strengthen the link between the HPSR community and policymakers.

Results

Based on our research and the consultative meeting, we developed a model for a sub-Saharan African network for HPSR. The model included a mechanism to strengthen linkages between policymakers, media, civil society, and researchers. The model also facilitated knowledge translation for policymaking purposes. We presented our model, recommendations, and an investment case for the Rockefeller Foundation to support the development of a sub-Saharan African network for HPSR.

With support from the Bill & Melinda Gates Foundation and in partnership with the International Initiative for Impact Evaluation (3ie), ThinkWell supported a review on the implementation cost of cluster randomized controlled trials (CRCTs). The goal of this evaluation was to better understand the cost drivers of CRCTs by collecting and aggregating expenditure data from a subset of recently published CRCTs globally. Working with research teams from finalized CRCTs, ThinkWell analyzed expenditure data to understand what drives the cost of CRCTs in different geographic areas. The results of this analysis provided donors with a robust data set on which to base their future funding decisions CRCTs.

ThinkWell conducted an analysis to identify bottlenecks to achieving universal health coverage (UHC) in selected countries from the World Health Organization (WHO) Eastern Mediterranean Region.

The analytic approach drew on ThinkWell’s implementation experience and augmented existing UHC assessment frameworks to examine the role of political, fiscal, cultural, and historical factors in scaling-up UHC.

Rigorous qualitative research applying ThinkWell’s UHC assessment framework was conducted in Morocco, Jordan, and Lebanon. Lessons from the study were disseminated to WHO Eastern Mediterranean Region countries.

Summary

The African Development Bank (AfDB) commissioned ThinkWell to study civil society-initiated participatory governance methods across Africa. ThinkWell’s team of researchers conducted a comprehensive landscaping review of civil society-led participatory governance methods in Ethiopia, Tunisia, Malawi, Mozambique, and South Africa. Based on these findings, the team conducted key informant interviews with leaders of civil society organizations to elucidate how participatory governance methods were used and what factors influenced how they worked. We captured the diversity of participatory governance across the five countries, cataloguing the range of methods and factors that influence their effectiveness. We identified 23 distinct methods and developed a new entry points framework, grouping each of them by where citizens can engage. Based on the findings from the five country case studies, we developed a political space analysis tool that links a country’s context and project objectives to method selection.