This blog post written by Lara Gautier was published today on the BMC Series Blog.
Universal Health Coverage (UHC) has recently become very popular in international forums: the 2016-approved WHO development agenda consecrated UHC as Sustainable Development subgoal 3.8. Thus, many of the “old” health financing policies get re-framed in the language of UHC. One question that may arise is whether national governments actually embrace the concept and decide to implement strategies that will achieve this (almost sacred) goal.
As I started my career as a junior professional in global health in West Africa, something caught my attention: the relationship between foreign donors and African governments. In many situations, my assessment was that there was something problematic with this relationship, something that somehow impeded the success of interventions.
Too many times I was witnessing international projects being implemented with little consideration for the public system in place or the people’s needs. I was witnessing inadequacy between what foreign donors (NGOs, private foundations, as well as international organizations and bilateral donors) were offering and what would actually make sense on the field.
Once, I saw a renowned international NGO recruiting community health workers before sending them to rural and remote villages. However, these CHWs were not originally from these areas: they came from the city. Most likely, their ability to integrate in communities and do a proper job would be undermined by this simple fact. I was not judging – there are good intentions behind this apparent mismatch – but simply realizing that it was worth investigating further. And so I embarked on the PhD adventure, in the field of health systems financing.
Governments in the driving seat?
One of the reasons I chose to specialize in this domain was that I thought this would be an area where governments would definitely have a say. Governments had to be in the driver’s seat because they would certainly care what sort of financial model would better provide healthcare in the whole country.
We chose to do a rapid review of what ownership actually implied for countries when decisions were made.
They would care because: 1) their budget is always tight (yes, tighter than ours) and 2) their popularity partly depends on the health status of their population. Idealists – myself included – would add to these self-regarding motives a genuine will to provide better and more accessible healthcare to populations. And this would, in turn, contribute to legitimize their power (some readers will probably think of Foucault at this very moment).
So I started investigating ownership of the policy making process in health financing. The problem was that, I was not at all convinced by the word “ownership”, which to me perpetuated – again – the representation systems of external donors. In the introduction of this article, we attempt to explain why the term, which got paired with other words (country, national, etc.), is problematic.
To depoliticize the word, we chose to do a rapid review of what ownership actually implied for countries when decisions were made. We came up with the following indicators of government ownership: political commitment by demonstrating leadership at the highest levels of government, effective engagement of technical levels of government, ability to coordinate international donors and partners’ support within public bodies, and national mobilization of domestic resources to finance the policy in the long term.
UHC involves many aspects (e.g. human resources for health, quality of healthcare), but we decided to focus on financing policies aiming at achieving UHC in Africa. The momentum was right, as several African countries had just undertaken major health financing reforms. We reviewed ownership of policymaking processes for three main health financing policies: user-fee exemption, health insurance, and results-based financing. Our review retrieved 35 papers, 24 of which showed mixed government ownership (i.e. there were indicators of ownership at some policymaking stages but not all).
We also found evidence that both government ownership and donors’ influence can successfully coexist.
Interestingly, when results demonstrated some lack of government ownership, we noticed that donors did not necessarily play a role: other actors’ involvement was contributing to undermining government-owned decision-making, such as the private sector. We also found evidence that both government ownership and donors’ influence can successfully coexist.
The results of our review show that, instead of pushing for new financing policies, donors should shift to strengthening the State’s coordination and domestic funding mobilization roles, together with securing a higher involvement of governmental (both political and technical) actors.
Short bio: Lara is a global health researcher currently enrolled as PhD student at School of Public Health (ESPUM) and Public Health Research Institute (IRSPUM) at Université de Montréal, and Paris Diderot University’s Centre d’Etudes en Sciences Sociales sur les Mondes Africains, Américains et Asiatiques (CESSMA). She coordinates the REALISME Research Papers collection.
Health financing policies in Sub-Saharan Africa: government ownership or donors’ influence? A scoping review of policymaking processes
Background: The rise on the international scene of advocacy for universal health coverage (UHC) was accompanied by the promotion of a variety of health financing policies. Major donors presented health insurance, user fee exemption, and results-based financing policies as relevant instruments for achieving UHC in Sub-Saharan Africa. The “donor-driven” push for policies aiming at UHC raises concerns about governments’ effective buy-in of such policies. Because the latter has implications on the success of such policies, we searched for evidence of government ownership of the policymaking process.
Methods: We conducted a scoping review of the English and French literature from January 2001 to December 2015 on government ownership of decision-making on policies aiming at UHC in Sub-Saharan Africa. Thirty-five (35) results were retrieved. We extracted, synthesized and analyzed data in order to provide insights on ownership at five stages of the policymaking process: emergence, formulation, funding, implementation, and evaluation.
Results: The majority of articles (24/35) showed mixed results (i.e. ownership was identified at one or more levels of policymaking process but not all) in terms of government ownership. Authors of only five papers provided evidence of ownership at all reviewed policymaking stages. When results demonstrated some lack of government ownership at any of the five stages, we noticed that donors did not necessarily play a role: other actors’ involvement was contributing to undermining government-owned decision-making, such as the private sector. We also found evidence that both government ownership and donors’ influence can successfully coexist.
Discussion: Future research should look beyond indicators of government ownership, by analyzing historical factors behind the imbalance of power between the different actors during policy negotiations. There is a need to investigate how some national actors become policy champions and thereby influence policy formulation. In order to effectively achieve government ownership of financing policies aiming at UHC, we recommend strengthening the State’s coordination and domestic funding mobilization roles, together with securing a higher involvement of governmental (both political and technical) actors by donors.
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