Public Financing for UHC: Towards Implementation

Building partnerships between MOH and MOF: Is it possible?

Midori de Habich Montreux, 31st November, 2017

Thinking about the relationship between the Ministry of Health and the Ministry of Finance when reform is on the table.

• What do we have in common?

• What sets us apart?

What do we have in common?

BEST HEALTH OUTCOMES

MINISTRY OF FINANCE

MINISTRY OF HEALTH

First generation reforms: Macroeconomic reforms

Second generation reforms: Institutional reforms

Priorities Inflation; growth. Social conditions; Health and Education.

Reform strategies Change of macroeconomic rules. Reform of the provision public services

Stakeholders Presidency, MoF, Economic Cabinet, Central Bank, financial groups, multilateral financial agencies.

Presidency, sector ministries, MoF, Congress, media, public bureaucracy, public sector workers and unions, political parties, NGOs, etc., etc., etc.

Impact of reforms Immediate. High public visibility.

Medium and long term. Low public visibility.

Technical and administrative complexity

Moderate to low. Very high.

Institutional challenge

Macroeconomic administration by insulated technocratic elites.

Institutional development highly dependent on mid level public sector management.

What sets us apart?

Adapted from Naim, M. (1994) Latin America: the second stage of reform, Journal of Democracy, vol. 5, No. 3, Washington D.C., National Endowment for Democracy.

What sets us apart?

A B

FIRST GENERATION REFORMS

MINISTRY OF FINANCE

SECOND GENERATION REFORMS

First generation

reforms

MINISTRY OF HEALTH

It’s all about designing the policy. The market takes care.

Implementation really matters. No invisible hand. Messy!

So, where do we go from there?

• Stakeholders

• Time frame of impact

• Technical complexity

• Institutional challenge

What I learned (provisional)

• Get the President´s Ear “First define the budget of Health and Education and after the rest of ministries”.

• Engage with a wide range of stakeholders Input and support from other ministries in the Cabinet

(most likely, social sectors) and Congress. Joint decision making with regional/local governments.

Personal contact with influential media and academia representatives to keep them informed and supportive.

When possible, form coalitions to bring political support but NOT against the MOF.

Stakeholders

• Adopt a dual focus on short-term wins and medium-term planning

Fully spending the year’s health sector budget and improving financial controls in the near term can help increase the MOF’s willingness to engage in three-year budgeting exercises that provide increased flexibility in health spending. “If I can tell you how much, you can tell me how long”.

Time frame for the impact of reforms

• Institutionalize a regular consultative process between health and finance agencies among both senior and mid-level staff. This process should supplement formal budget negotiations with more frequent meetings, and can help to build rapport and understanding.

• Support budget negotiations with good-quality, shared

information on value. Value is a function of results over cost, and therefore it is important to present data on both health outcomes and expenditures.

Technical complexity

• Invest in personnel in both MOHs and MOFs that are well-versed in the technical language and mind frame of the counterpart institution For example, economists in the MOH and public health specialists in the MOF. “Hire them, train them and retain them”. Combined with a regular consultative process, this can help bridge the divide and sustain dialogue regarding the complexities of health reform and the need for health financing reform.

Institutional challenge

Assessing and monitoring institutional capabilities

A tunnel vision to avoid The policy cycle to change

In a broader scope

Institutional challenge: where are we starting from?

33%

35%

19%

13%

1996-2006

Andrews, M., Pritchett, L., Woolcock, M. (2017) Building State Capability, Oxford University Press.

Much discussion about health financing reform. How do incentives finally impact on more efficient, equitable and better quality services? A black box for economists? Integrate discussion on health financing reform with service delivery reform.

Avoid a “new” tunnel vision

A B

or none at all

A policy cycle to change

Not so difficult?

Acknowledges and assesses previous reforms

Formulates the solutions to fit the problems

and the capabilities Identifies low hanging

fruits from previous policies Prioritizes outstanding

performance problems

Thank you

Midori de Habich Montreux, 31st November, 2017