Presentation given by Barbara McPake at the Nossal Institute for Global Health, University of Melbourne, in July 2015

1. Funded by
Health financing in
post conflict settings
 Barbara McPake
 Nossal Institute for Global Health
 School of Population and Global Health
 University of Melbourne

2. Funded by
Health financing debate in LMICs -
summary of main issues
• Since late 1980s, debate about the mechanisms by which funds flow
from individuals and households to health service providers
• taxation system - can fund use of public or private health providers
• insurance systems - public and private
• out-of-pocket payments - in public and private sectors
• Clear consensus from a body of research that out-of-pocket
payments significantly deter use of health care where important
• Further conclusion that out of pocket payment (% in total health
financing) and ‘catastrophic’ payment (incidence) strongly correlated

3. Funded by
• However, early evidence that ‘user fees plus quality
improvement’ can maintain or increase use of health care
• Raises tension between effects of intervention on demand and
supply sides and their inter-relationships
• Also raises issues of distribution of impacts - unlikely to be
uniform change in use of care across population groups
• Measures to target groups likely to be most negatively
impacted - for example exemption systems have largely
worked poorly though some experience of funded exemption
has been better.

4. Funded by
• Generating sufficient resources to provide effective
services may not be feasible through the tax system -
either for economic or political reasons
• Insurance mechanisms may better protect and stabilise
health budgets
• Public insurance systems operate similarly to tax - limits to
fiscal space and politics constrain them
• Private (voluntary) insurance systems exclude important
population groups and increase inequities - although they
may work well for large sections of the population
• Community based insurance systems focused on poorer
populations require subsidy; still often exclude the poorest

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• More attention in last decade to the need to support the
‘supply side’ while removing constraints to the ‘demand side’
• Recognises constraints to subsidy levels by focusing subsidies
on target services - for example maternal and child health
• Large numbers of countries have aimed to remove out of
pocket payments while channelling additional resources to
compensate for the loss of revenues
• Mixed results - difficult to channel resources in ways that
generate incentives for effective care delivery, but some
successes

6. Funded by
ReBuild program
• 6 year 6 partner research program funded by UK DFID
• Partner institutions in UK, Cambodia, Uganda, Sierra Leone
and Zimbabwe
• ‘Path dependency’ idea at centre of design. What is possible
with respect to policy development in post conflict period
(short post conflict lens: N. Uganda and Zimbabwe)? What is
the long term impact of changes made in the post conflict
period (long post conflict lens: Cambodia and Sierra Leone)

7. Funded by
• Much stronger emphasis on the role of aid in these settings
• manage transition from humanitarian to development aid
• strengthening government stewardship and capacity
• coordination
• impact of Global Health Initiatives

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• Equity impacts of conflict create some unusual distributional
contexts
• Conflict may have ‘levelled down’ the economic situation of
the population
• May be strong regional patterns in distribution of impacts of
conflict
• Pre-conflict inequities may differ from post-conflict
inequities and distributional questions may need to be
considered from both perspectives
• Free health care may be part of a post-conflict citizenship
rights settlement

9. Funded by
• Context of health care provision - generally larger role for
NGOs than in stable states
• Provision transition expected to accompany aid transition and
financing transition - shift of service delivery to public sector
• But in practice, two main trends in health financing post-
conflict are an increasing reliance on informal payments and
donor funding

10. Funded by
• Strong parallels between user fee analysis in conflict affected
settings and LMICs more generally
• Greater emphasis on maintaining whatever is working and has
survived the extremes of conflict conditions - often fee-paying
NGO facilities
• Afghanistan has provided a case study of successful exemption
policy in a post-conflict setting
• Cambodia has demonstrated positive impacts of health equity
funds - funded exemption system
• Rwanda has had most success with highly-subsidised
community based insurance mechanism

11. Funded by
• Significant gaps in the literature
• Weak literature methodologically - few papers proceed on
the basis of clear methodology; piecemeal and small scale
studies
• Weak definitions of ‘fragile and conflict affected states’.
Grouping highly diverse contexts facing very different
challenges without clear basis of differentiation
• Focus overwhelmingly on role of donors - much less
attention to role of government policies
• Emphasis on immediate post conflict period - few studies
with longer perspective

12. Funded by
 ReBuild work in this area aimed to use our four case studies to
strengthen the understanding of the impacts of health
financing policies on poor people in post conflict contexts
 4 very different contexts
 Different sets of health financing policies and changes
 Different data opportunities
 2 case studies (Sierra Leone and Uganda) illustrate these
issues – both unfinished work in progress.

13. Funded by
• Current cost recovery scheme introduced 2006 - flat fee
charged for all health services except medicines for which full
cost recovery fee applies
• National guidelines to exempt children, adults over 60,
pregnant/lactating women and disabled
• Poorly implemented - group too large for resources at facility
level; few in fact receive waivers

14. Funded by
• Free Health Care Initiative April 2010
• Children <5; pregnant and lactating women - free care -
funded by government and donors
• Range of health sector reforms - medicine supply
management, human resources management
• In first few months, use of health care by target groups
increased sharply, but then gradually declined
• Decline associated with shortages of medicines, informal
charges

15. Funded by
• Study seeks to:
• quantify impact of FHCI on child and maternal health
service use and out of pocket payment
• for children: a regression discontinuity design using 2011
Sierra Leone Integrated Household Survey (SLIHS)
• for mothers: a time-trend adjusted before-after estimation
approach using 2013 Sierra Leone Demographic and Health
Survey (DHS)

16. Funded by
• SLIHS - nationally representative household survey 6800
households. Study uses subsample of children 0-120 months.
Data on out of pocket payment, utilisation (used outpatient
care in two week period preceding interview) in public and
private facilities but excluding NGO facilities.
• DHS - 16,658 women of reproductive age, most recent child
birth over 5 year recall period and services received -
information exists on births occurring before and after FHCI

17. Funded by
• Regression Discontinuity Design - exploits discontinuity in
entitlement to free health care in relation to child age. If FHCI
effective, a trend discontinuity at 60 months expected.
• However, not all children < 60 months succeed in receiving
free health care and some non-eligible children will have done,
so => ‘fuzzy RDD’
• Time trend adjusted before-after estimation approach - 4
binary outcome variables compared - 4+ ANC visits; delivery in
public facility; vit A supplementation up to 2 months; DPT+
vaccination in first year.

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Descriptive results: children

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22. Funded byDescriptive results: women

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• Results statistically significant (though small) for simple
comparison
• After time trends and interaction terms included, no longer
significant for facility births, delivery with skilled health
workers or 4 ANC visits for all facilities
• But significant for ANC, PNC, vit A and DPT+ significant for
public facilities and fairly substantial for PNC, vit A and DPT+
• Effects larger and more significant in rural areas

24. Funded by
Before
After

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• No clear impact for children - might relate to lack of clarity
about which children were exempted
• DHS suggests increase in service use for children but may be
longer term trend as there appears to be for women
• Statistically significant increases in service use for women,
substantial for some indicators and for rural areas
• Overall disappointing impact may relate to continued costs,
medicine shortages, targeting errors, insufficient supply side
reforms

27. Funded by
Self-reported health, health utilisation, and
food consumption in the post IDP camp
period in Uganda
• Fu-Min Tseng, Tim Ensor, Ijeoma Edoka, Robert
Bataringaya, Sarah Ssali and Barbara McPake

28. Funded by
• Armed conflict Northern Uganda from early 1990s
• By 2005, 2m internally displaced persons (IDPs) including 90-
95% of the population of Acholiland
• Government declared it safe to leave camps in late 2006
• By 2009, IDP population had fallen to 450,000

29. Funded by
• As people return from camps…
• reduction in exposure to camp specific risks including
infectious disease, stresses of displacement, lack of life
choices
• access to health services may worsen as camp services
inaccessible
• need to re-establish livelihoods, planting cycles, housing
and land rights - basic services including health may be
secondary

30. Funded by
• Study investigates changes in health indicators, healthcare
utilisation and food consumption of people living in districts
highly affected by internal displacement over the period in
which most returned
• Analyses the Uganda National Household Surveys of 2005/6
and 2009/10 using difference in difference method
• ‘Treatment group’ = 3 districts most exposed to conflict;
excluded = 9 districts partially exposed to conflict; ‘control
group’ = remaining districts not exposed to conflict
• 5 outcomes - self-reported illness incidence in past 30 days;
productive day loss caused by illness in last 30 days; visits to
health facilities in the past 30 days; health expenditure in last
30 days; food consumption in the past 7 days

31. Funded by
• Descriptive statistics

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• No significant evidence that self-reported health and
frequency of healthcare utilisation changed after IDPs
returned, but evidence of significant increase in food
expenditure
• Insignificant change in self-reported health may balance
counteracting effects of fewer camp related risks but more
limited availability of infrastructure and services.
• Shift from formal private to informal care - probably reflects
differing range of options.

34. Funded by
Overall conclusions
• Literature on health financing in post conflict contexts is
limited
• Post conflict contexts are varied; policies diverse and data
opportunities variable, so 4 case studies, even when fully
complete will only add marginally
• Many of the issues appear similar to those in other LMICs
• Others specific to particular conflict related phenomena such
as IDP return
• Any level of generalisation will have to wait.