Synopsis
As health systems in developing countries are challenged
to finance growing demands for services, national governments
and international donors are looking at innovative ways
to protect targeted populations from the financial risks
of illness. During this session, two innovative strategies
of targeting and providing services will be discussed:
The first half of this seminar is titled, “Improving
Health Care Systems Using Geographic Information Systems
(GIS).” Mr. Mark Landry will describe how integration
of health-related inputs into a GIS creates a powerful tool
for improving efficiency and effectiveness of health care
systems. Four state-of-the-art health GIS applications under
development in Yemen will be described: 1) mapping health
facilities and analyzing accessibility areas; 2) using GIS
to target health care program interventions; 3) donor mapping;
and 4) plotting the spatial pattern of the 2000 Rift Valley
Fever outbreak. The seminar will address how health GIS
applications provide evidence-based rationale for targeting
health care system interventions.
The second half of this seminar is titled, “Community-Based
Health Financing Schemes/Mutual Health Organizations (MHO)
Grow Up.” Mr. Marty Makinen will discuss the transition
of MHOs from local initiatives to national programs, and
the role of the government and USAID technical assistance
in facilitating the transition. Participants will be able
to appreciate the complexity of 'scaling-up' community-based
MHOs to national-level movements/programs. Can community-based
initiatives scale up and keep their souls? The session will
look at the different scaling-up experiences of MHOs in
Senegal, Rwanda, and Ghana, and at clues for future development
in Mali and Benin.
Notes
The ninth Seminar in a series of twelve, “Innovative
Health Care Approaches” was organized by Bryn Sakagawa
of the Global Health Bureau. All of the presenters came
from the Partners for Health Reformplus (PHRplus) Project,
a five-year, one hundred million dollar contract managed
by Abt Associates, Inc and partners and that focuses on
health reform in about 30 countries around the world.
The first speaker, Mark Landry, Geographic Information
Systems (GIS) Specialist, discussed health GIS applications
for improving efficiency and equity of health care interventions
in developing countries. Sara Bennett, Manager of the Applied
Research Program, and Pia Schneider, Health Economist, outlined
the importance of, challenges to, and lessons learned from
community-based health financing (CBHF) schemes. Bennett
and Schneider discussed CBHF in Ghana, Rwanda, and the Philippines.
Geographic Information Systems (GIS)
Mark
Landry defined Geographic Information Systems (GIS) as “a
database with legs that allows a person to interlay and
visualize information…and to analyze trends and relationships
spatially.” The health database contains a broad range
of health-related information, for example, health statistics,
demographics, health care resources, and digital pictures
and global positioning system (GPS) coordinates of health
facilities. GIS permits the user to examine relationships
among a wide variety of factors, including health data,
population characteristics, environmental conditions, and
more.
Landry specializes in GIS applications in the health sector
and explained how ‘health GIS’ works. Health
GIS is structured in layers—with a foundation of base
map data layers (roads, elevation data, etc.) underneath
mapped demographic data, and with the superior layer showing
mapped health facilities, such as pharmacies and clinics.
Through its surveillance systems, surveys, and health information
systems, GIS enables an expansive array of applications—such
as aiding in the integration of health information systems
(HIS), as well as determining the availability of and access
to health care and equity and efficiency of health service
delivery.
Landry gave a brief overview of ongoing health GIS efforts
in Yemen, including continuous collection of health-related
data, the development of customized health GIS analyses
and the implementation of HIS in pilot health centers. He
showed how GIS could map the distribution of governorate-specific
projects by type and spatial patterns of outbreaks of Rift
Valley Fever in 2000. Integrating HIS with GIS has improved
data collection efficiency and provided a method of evaluation
and monitoring for evidence-based health care pattern improvements.
Despite the many benefits of geographic information systems,
there are some barriers to overcome. Relying on existing
data sources can often be problematic as can collecting
and integrating enormous amounts of data, sometimes from
various sources. Health data cleaning and spatial rectification
are important early steps to ensure appropriate use of the
best available data sources. However, GIS brings some important
implications for the health industry. It reveals new relationships
and trends, illustrates evidence-based rationale, and allows
for sophisticated and robust spatial analyses.
Scaling Up Community-Based Health Financing (CBHF)
The
Partners for Health Reformplus (PHRplus) Project has provided
mostly small-scale technical assistance in establishing
and maintaining community-based health financing (CBHF)
schemes. Though these small-scale programs have rapidly
proliferated and flourished, the problem still remains of
graduating to a more comprehensive, national-level health
care system that would provide financial protection against
health care cost for a broader community.
audience for the Health Care seminarThe importance of community-level
insurance is evident in the relatively small numbers of
the lower-income ill who consult a health care provider.
As people in higher-income brackets have higher rates of
seeking treatment when ill, Bennett and the team have deduced
that user fees charged by health care providers are too
high for lower-income groups and consequently restrict healthcare
access.
CBHF schemes, driven by community members or health facilities,
aim to improve financial access to health care. The project
has determined that the following preconditions be present
for the CBHF scheme to work: (1) willingness to pay for
healthcare, (2) trust in the CBHF scheme, and (3) availability
of providers that offer quality care. Assuming that these
conditions are met, the population gains protection against
the costs of illness. As a result, scheme members of a well-established
CBHF scheme have a significantly larger probability of accessing
healthcare than user-fee paying individuals.
The international community has found CBHF to be an appropriate
mechanism to finance health services without causing too
much pain for the population. (As an aside, Bennett remarked
that there seemed to be a limited amount of data to support
this claim.) Though the number of schemes has grown over
the years, scheme membership is still very low—few
low-income countries have more than one percent of their
populations enrolled in schemes.
Bennett explained the process of scaling up by using an
inverted triangle, the bottom of which represents low levels
of institutionalization and a small government role characterized
by a dominant out-of-pocket payment system, with the top
representing high levels of institutionalization and a national
policy framework typical of a universal insurance coverage
system. The major challenges to scaling up include: ensuring
equity among members through government adaptation of resources,
preventing financial instability and implementing regulations
to protect members from fraudulent schemes.
In August 2003, Ghana passed the National Health Insurance
Act, which mandated that all districts establish CBHF schemes
funded by sales tax, formal sector worker contributions,
and voluntary payments by informal sector workers. The Ghanaians
faced problems with client education and high (sometimes
locally unachievable) standards of care. The major lessons
learned from Ghana’s trial with a national standard
of CBHF were: ensuring that the necessary infrastructure
exist prior to legislation (as many locals lacked capacity
upon nation-wide rollout) and that the government’s
level of funding be sustainable.
Pia Schneider presented two dichotomous approaches of schemes
in Rwanda and the Philippines. Rwanda has chosen atwo presenters,
Bryn and Pia replication strategy whereby the government
has replicated CBHF pilot schemes in other parts of the
country. At the end of the PHR Project’s first year
(1999), the 54 pilot schemes had more than 88,000 members
or roughly 10 percent of the population. These schemes were
replicated in other districts.
Since 1999, CBHF schemes have grown from 54 to about 120.
In the original three districts, more than 20 percent of
the population is now enrolled in CBHF schemes. Some replication
programs are funded by USAID, while others started up on
by their own or are funded by other donors. Rwanda faces
several challenges to CBHF scheme implementation, including
lack of human and institutional capacity, premium levels
in excess of what the poorest can afford, and low levels
of quality care (which affect willingness to insure). The
PHRplus Project found that CBHF replication requires a sound
legal framework and a National Health Financing Strategy,
subsidization of premiums for the poorest households, and
monitoring and evaluation of the schemes’ financial
performance and providers’ delivery of quality care.
The Philippines involved the integration of CBHF into national
health insurance. In 2003, 40 million people or about 50
percent of the population were enrolled in a national health
insurance plan PhilHealth. The Universal Coverage Law mandated
compulsory insurance enrollment for both formal and informal
sector workers (including independent workers) and for the
poor with government subsidization.
Schneider pointed out some political interference that
affected the scale-up of CBHF. First, while only 25 percent
of the poor were enrolled pre-election, more than 100 percent
were enrolled post-election. Second, she brought attention
to the use of the mayor’s picture on the back of the
membership card, which confused the poor as to what the
card was intended for. In addition, there is a general lack
of solidarity among the populace, as the rich tend to opt-out
of the universal care plan and enlist with private insurance
companies.
Lessons learned from the Philippines were similar to the
Rwanda pilot project. Countries should have a sound institutional
framework, the organizational capacity to build a national
health insurance system, financial sustainability and equity
in financing, and be ready to provide for monitoring and
evaluation of provider and insurance performance.
After considering the two approaches, Schneider concluded
that there is no single way to achieve universal health
coverage—the program must adapt to the socio-economic
conditions of each country. In addition, the government
must take ownership of the scaling-up process. Schneider
emphasized the need for maintained client trust in the health
system if scaling-up of insurance coverage is to be successful.
Schneider concluded her presentation with recommendations
for technical assistance in the following areas: (1) individualSara
and Joe Lieberson discuss innovative health care approaches
schemes, (2) institutionalization of local technical assistance
capacity, (3) development of a financing policy, (4) establishment
of legal frameworks, and (5) measurement and evaluation
and documentation.
Question and Answer Session
Have you done any excavation of using GIS in Iraq?
Landry: I don’t think we’ve
used GIS in Iraq to date and I don’t know if we will.
Can you talk about the decision making that you’ve
seen in Yemen based on GIS? Can you also discuss your efforts
to build the capacity of local health people to use information
gathered by GIS? Do you have any suggestions for the use
of GIS (maybe through GPS noting) in regular monitoring
and evaluation in health?
With respect to your first question,
we have only been there for a year and we have the base
of GIS ready to go and are currently working to build up
specific health GIS applications. However, the Yemeni Ministry
of Health are currently using donor mapping we provided
to help them identify places where donor programs already
exist and places that need donor support. In order to roll
out health GIS applications, we are building out three types
of GIS analytical tools: one for USAID, one for the national
level—Ministry of Health, and another for the field
(in terms of easy-to-use, standardized queries). In terms
of using GPS, there are great opportunities for all types
of surveillance and monitoring.
I see GIS as a wonderful tool for post-war developing
nations and putting together a comprehensive program for
long-term planning, not just for health care, but also for
education or agriculture.
That is certainly on the
table for next steps. USAID is very much interested in the
base map data and potential cross-cutting uses. There are
a lot of integrated analyses that can be done, especially
with agriculture.
First, my experience trying to use these types
of applications in data poor and spatially challenged countries,
we must realize that when you have poor data, you can use
them to identify where the gaps are, but you have to make
sure that you do not disempower the local people. It is
important to have local people provide input and validate
the data. Second, with this technology you can show spatial
and geographic inequalities. Also, we’ve tried to
show some of the socio-economic inequalities three-dimensionally.
Have you ever tried that?
In Yemen, we already have district level health facility
maps in place. The local people are involved and they get
excited about seeing the data that they have contributed.
The only 3-D example of complex analyses that I can think
of is choropleth mapping that includes sliding bars and
multi-variable analyses. You can have 3-axises and provide
map outputs showing that type of information. That is something
that I’ve seen mostly in first-world countries because
it requires more sophisticated data sets.
Looking on a long term horizon, what is it going
to take to maintain the system? What are the relative costs
of this versus another system? To what extent is the Ministry
really committed to taking over this process and building
ownership of the system?
In Yemen, the Ministry
of Health is very much on board. Once you’ve paid
the start up cost, you really just need to have the manpower
and training to maintain it. I think the costs are very
reasonable in comparison to maintenance other information
systems.
Q & A - Scaling Up...
Do you limit coverage for certain things so the
scheme doesn’t go bust?
On the provider side,
when coming up with a scheme you have to ask how much does
it cost to cover the benefit package and based on that you
can calculate your premiums. On the client side, we had
meetings with the community representatives and asked them
what they would like to have covered and how much they are
willing to pay for premium. The benefit package was then
defined based on the costs of providers and the amount people
were willing to pay for premium. In this way, the coverage
can be specific to the local context.
For sub-Saharan Africa schemes, to what extent
is preventative health incorporated versus post-illness
treatment.
The extent to which preventative health
measures are incorporated depends upon what the individual
community wants. For example, pre-natal care is often in
included.
On either side of your inverted triangle, you have
government and donor roles. What about the role of the community?
I know that most communities already have their own welfare
system when member of the community is sick. How can you
use that to increase the coverage of the poor?
Many of the CBHF schemes have built upon traditional
risk-pooling mechanisms, such as Tontines. The reason that
the community is not more representative here is that we
were thinking more about the scaling up issue, that is do
you move from the small schemes to a nation-wide health
safety net? Also, these traditional safety mechanisms are
not really protecting the poor. Traditional methods are
important systems to build upon and they help when it comes
to teaching the locals about CBHF schemes. We’ve seen
faster scheme growth in West Africa, which has these traditional
mechanisms, than in East Africa, which lacks traditional
safety nets.
Regarding monitoring and evaluation and learning
doing—What have you learned about monitoring and evaluation
and what recommendations do you have?
We’ve
learned that it’s difficult and that there are different
clients for monitoring and evaluation. The burden of monitoring
and evaluation typically falls upon the scheme managers
and they have very different needs than those providing
technical assistance might have. We’ve tried over
the past 2 to 3 years to establish routine monitoring systems
with the schemes. The hardest part of the issue is having
different clients that have different informational needs.
People don’t do monitoring and evaluation because
they see the filling in of a data sheet as additional work.
Once people see the benefits of monitoring and evaluation,
they are more willing to do it.
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