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USAID Summer Seminars

Session 9 - Notes

The Bureau for Policy and Program Coordination, in coordination with the Knowledge for Development Subcommittee, is pleased to present USAID 2004 Summer Seminars. If you have further comments or questions, please visit our WebBoard (new page will open).

Tuesday, August 31, 2004 9:00-11:00
Notes for the ninth session of the 2004 annual USAID Summer Seminar Series, “Innovative Health Care Approaches” Question and answer portion here.

Bryn Sakagawa, USAID/GH

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.

The 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 a 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) individual 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.

Q & A - GIS

1. 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.

2. 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.

3. 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.

4. 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.

5. 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...

1. 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.

2. 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.

3. 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.

4. 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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