How can existing resources be used more efficiently and equitably?

While there is an absolute shortage of resources in African health systems, it is also possible to improve efficiency and equity in the use of existing resources to better meet the health needs of the population.

A key intervention in many African countries in recent years has been the introduction of performance based financing. More and more countries have been turning to performance based financing (PBF) to improve results in their health sectors due in part to growing recognition that African countries would not achieve the MDGs on current performance and progress, and that health sector financing strategies based on paying for inputs (numbers of personnel on the payroll and for their training, equipment costs, operational budgets, etc.) have not produced hoped-for results in the sector.

PBF can be implemented on the demand or the supply side. On the demand side, this includes conditional cash transfers and voucher schemes where the beneficiaries of priority health services (e.g. maternal and child care services) are provided with cash or vouchers to purchase the care needed from providers. On the supply side, this approach puts the emphasis not on paying for inputs, but rather on the results obtained (numbers of children vaccinated, numbers of assisted deliveries, numbers of women on family planning, etc.). It is premised on the notion that incentive payments to personnel will bring about behavioural and other practical changes that will lead to better productivity and quality health care. Financial incentives may be introduced at different levels of the health system although more often these are targeted at priority health services.

Experience shows that PBF implementation usually involves different actors (Ministries of Health, health facilities, NGOs, health personnel, etc.). It entails establishing either some agreed sets of rules or contracts between the different parties. The incentive payment to be paid to the provider is calculated on the basis of indicators of quantity of services performed, which may then be weighted by quality indicators. The total payments obtained from this process tend to be shared among the personnel in accordance with their contribution to the production of those services, but in some cases, part of the funds will go to investing in facility operational or capital costs to further improve quality.
 
The idea is that through this additional remuneration of health personnel and the stronger monitoring mechanisms this entails, other end results will include improvements in the organisation of services, in the production and use of data for decision making and also in the utilization of health services as well as greater efficiency and equity in resource utilization.
Like other reforms, PBF is not without challenges or even critics. Box 6 highlights some of the issues in the on-going debate on PBF.

Box 6: PBF challenges and debates

Among the challenges of the PBF approach, mostly related to the supply side PBF reforms, are that:

  • This approach may require prior institutional and organisational changes, particularly decentralization and local autonomy for health facilities, to make these reforms effective.  The required changes may include purchaser-provider splits, putting in place effective and functioning verification systems, and creating a favourable legal/regulatory environment. The challenges here may also include existing trade union or collective bargaining agreements that may be inconsistent with the new incentives’ approach.
  • Adequate and sustained funding is needed to back the new system. While some of these resources may come from redirecting existing input-based financing budgets, experience seems to show that significant amounts of new financing is often required, both during the demonstration and rolling out stages, including for new monitoring and evaluation systems and training of the personnel in the new systems, data collection methods, indicators that are monitored, etc.
  • It is also argued that while PBF schemes may lead in the short term to desired changes and improvements, evidence also points to the fact that people eventually adjust to new incentive systems and then start to regard them as part of their regular remuneration or ‘asking price’ for their job, at which point these mechanisms may then lose their incentive effect. This argument highlights one key challenge in mainstreaming PBF reforms within the regular MOH systems. Current PBF schemes in Africa may not however have been in place long enough to test this hypothesis.
  • Finally, there is also some debate as to whether the evidence emerging from countries where these reforms have been implemented is sufficiently robust and unambiguous enough to warrant widespread adoption elsewhere without some degree of caution. While Rwanda, and to some extent Burundi, have often been cited as success stories in this respect, it appears that some counter examples from other countries, e.g. Uganda and Cameroon, may also exist.

The debate seems to highlight, at least, the need for careful attention to the design, financial sustainability, the political, social and institutional environment, any necessary accompanying measures, as well as a health systems rather than a vertical approach, in pursuing the PBF approach.

Health professionals are the most important resource within the health sector and if efficiency is to be achieved, careful attention must be paid to the skills mix within health services. An initiative that is being implemented in many countries is that of task-shifting, whereby more mid-level health workers are being trained and tasks that used to be undertaken by more highly-skilled health professionals are being shifted to these mid-level workers. This promotes greater efficiency, in that each service is provided by the lowest skilled (and hence least expensive) health worker qualified to provide that service.

It is also critical to improve the procurement and distribution of drugs. Many countries have introduced essential drug lists, which focus on the use of a limited number of inexpensive generics that can treat the majority of diseases within that country.  In terms of procurement, there is a need for policies that ensure that African countries are not charged prices for drugs produced overseas that are higher than are paid in other countries. This is because there is limited local production of drugs, with most drugs being imported. Some national policies do not promote the growth of local drug manufacture. For example, in Zimbabwe, while drugs that are imported are not subject to import duties, local drug manufacturers pay duties on imported raw materials.
It is not only important to use existing resources more efficiently, it is also critical to promote equity in the use of health care resources. A number of recent studies have once again highlighted that richer groups manage to secure a greater share of the benefits from using health services than poorer groups, despite the burden of ill health being heavier on those with lower socio-economic status. Those living in rural areas also receive a smaller relative share of health service benefits than their urban counterparts.

One strategy for addressing these inequities is to allocate health care resources (facilities, financial and human resources) across geographic areas such as regions or provinces and districts in line with the relative need for health services of each area. A growing number of African countries are using a needs-based formula to allocate government budget resources and pooled donor funds. Such formulae generally include indicators of the need for health services in a geographic area such as population size, demographic composition (given that young children, the elderly and women of childbearing age generally have a greater need for health care) and if possible, indicators of the burden of disease.
 
Recent studies have recommended that the level of poverty in each area also be taken into account, given that there is a strong relationship between poverty and ill-health and that poor households are most dependent on publicly funded health services.
However, equity in the use of health services will only be addressed if explicit steps are taken to address the range of access barriers that face individual patients. A number of studies have recently highlighted that the most severe access constraints include the following:

  • The distance between communities and health facilities and the sometimes high costs of transport to facilities. There is particular concern about geographic access problems for referral services and in a medical emergency.
  • Inadequate staffing, particularly at primary care facilities, forcing patients to seek care at hospitals at higher cost both to the state and the patient.
  • Inadequate drug supplies, with frequent reports of drug stock-outs, again particularly at primary care facilities.  This means that patients have to then go and purchase drugs from a private pharmacy or drug seller and that patients are reluctant to go to that facility in future.
  • Poor staff attitudes towards patients, which is exacerbated by inadequate staffing levels and heavy workloads, but also by limited attention to motivating staff and recognising their efforts.

These access constraints highlight the importance of ensuring that there is an adequate allocation of resources to the primary care level and that sufficient attention is paid to improving the quality of primary care services. These are the services that are located closest to communities and much of the burden of disease in African countries, particularly communicable diseases, can be addressed at primary care level.

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