Saturday, September 19, 2020

Governance Issues in Health Financing: Implications for Botswana

This piece dear reader  provides an overview of the different definitions of governance in health, with a special focus on financing and related issues – ranging from the concepts of good governance in health to global-health governance.

The piece  also discusses the WHO’s work on health systems financing for universal health coverage, to justify better leadership and governance toward protecting the public interest beyond just improving health status.

Governance in the financing of health systems requires an oversight function similar to the concept defined as stewardship by the World Health Organization. It strives for a level playing field for all involved in the health sector, covering concerns over corruption and abuse from a lack of accountability and transparency to universal health issues of equity, effectiveness and equity.

Good governance of health systems seeks an optimum path to maintain a judicious balance between delivery and financing of health services with sound and proper regulation. Conceptually, it can be a force to achieve social justice and fairness in health systems, although the contexts may vary according to social norms and public expectations.

The literature on health system governance mirrors the broader governance literature. A variety

of definitions of health system governance can be found that draw on the broader concept of

governance and principles and dimensions of good practice have been developed for the health

Sector based on these definitions. There is also a literature on governance of the institutions that

comprise the health system.

Governance has been defined in a variety of ways. Broader definitions encompass politics, policy, public administration, the interaction of these with civil society and the private sector, and the effects the various institutions have on socio-economic outcomes.

Health system governance is governance undertaken with the objective to protect and promote the health of the people. Governance involves, setting strategic direction and objectives; making policies, laws, rules, regulations, or decisions, and raising and deploying resources to accomplish the strategic goals and objectives; and overseeing and making sure that the strategic goals and objectives are accomplished.

There is a reason why, I have to provide the above contextual framework, dear reader. It is for the benefit of some village professors and mombas, who still cannot make a connection of public health to the disciplines of public administration, politics and etc. However, that is subject of discussion for another day.

All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of Universal Health Coverage (UHC) is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability.

The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.

Unless the concept is clearly understood, “universal coverage” (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. Health Systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. 

Expansion of health insurance coverage offers promise in the quest for sustainable health care financing for many of the health systems. Tom Achoti and Abaleng Lesego (2017) have argued elsewhere that broader policy implications of expanding health insurance coverage have not been fully investigated and contextualized to many African health systems

Since the publication of the world health report 2010, 1 universal coverage (or UHC) has received increased attention. Like having a “sustainable health financing system”, it is something that sounds very good.

But what does it mean, exactly, and why is it something worth pursuing? The world health report 2010 contains the following definition of health financing for universal coverage: financing systems need to be specifically designed to: provide all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to be effective; (and to) ensure that the use of these services does not expose the user to financial hardship.

Financing is presented as a basic function of a health system that requires a clear identification of the roles of regulations and regulators, including ways and means to enforce the rules for proper behavior and the penalties for noncompliance.

Health financing has been commonly defined as consisting of the three essential sub-functions of  collecting revenues, pooling resources, and purchasing services, each with their specific requirements for governance. Peculiarities in health such as risk and uncertainty present certain consequences for governance, such as the need for insurance and associated hazards, together with the complexities of payment to influence the behaviors of doctors, patients, financing intermediaries, and government.

Among very specific challenges to governance in health financing are measurement, health outcomes, international issues, and universal health coverage. These are made even more complicated due to the differing systems of health financing and approaches, definitions of processes and outputs, and consensus of goals and values.

A framework of publicÔÇôprivate health financing is discussed along with the governance issues that usually appear for the provision and payment methods in financing systems, relating to the trade-offs between equity and efficiency in balancing costs, access, and quality.

Thus the issues of governance may involve even greater regulation over financial reporting and monitoring of financial information, as an essential part of the health management information system.

As medical technology advances, there would be greater need for providers to provide financial data to be linked to claims of better outcomes and quality of services.  These financing and related payment mechanisms must be regulated more effectively through checks and balances, but without incurring high administrative and transaction costs, so as to achieve the policy goals of effective, efficient, and equitable utilization of scarce societal resources toward Health for All.

Some of the debates around recent reform experiences, particularly those related to the interpretation of what is meant by “insurance”, suggest that there remains a lack of common understanding about the concept portrayed in The world health report 2010.

This is not merely an academic debate; conceptual differences create operational differences in terms of the health financing policy choices made by countries, what they are advised to do, and how reforms are assessed.

In Botswana, the government is committed to achieving universal health coverage and assuming a higher share of HIV/AIDS and other health spending, even though long-term economic growth prospects are less optimistic than in the past. To guide its path, the government developed a health financing strategy that increases efficiency, ensure financial sustainability, and promote an effective mix of public and private mechanisms for health financing and service provision.

Botswana has a mixed health care system composed of public, private providers and funders. Approximately 83% of the population relies on the nearly free public system for their health care, while the remaining 17% uses private providers and is covered by commercial medical aid schemes. The level of health spending per capita in Botswana is above average compared to other countries; however, government share of health expenditure has been declining relative to private sector financing. The government is now dedicating a smaller percentage of its total budget and a smaller percentage of GDP to health than neighboring countries.

There is an urgent need to make an assessment as to why the above is the case and make recommendations on how Botswana’s health system can be strengthened to avoid a situation where the private sector takes charge as well as to avoid situations where its health system is run by International NGOs and partner universities from abroad for many projects and programs.

The main conclusion acknowledges that governance is indeed critical for health financing but needs sound financial information to affect policy at all levels. Ultimately, the priorities for good governance are to determine proper roles and functions of financing within health systems that are well integrated in a balanced share of public, private, and voluntary sectors, to develop universal health coverage for all within an affordable and sustainable financing framework, and to strengthen health financing methods with improved financial management systems.

Food for thought as the President will be presenting his maiden SONA tomorrow.

Thabo Lucas Seleke, Researcher & Scholar, Global Health Policy & Health Systems Strengthening

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