Financing Primary Health Care: Opportunities at the Boundaries

June 13^th

8:00 – 9:30 EST : Side Event 1—Financial Protection in Health in the Covid-19 era –The Baseline, What to Expect, and How to Respond

Recording: English | French

Speakers: 

• Ajay Tandon, Lead Economist, World Bank
• Patrick Eozenou, Senior Economist, World Bank 
• Tamar Gabunia, First Deputy Minister, Ministry of Internally Displaced People from the Occupied Territories, Labor, Health and Social Affairs, Georgia 
• Gabriela Flores, World Health Organization 
• Shabnum Sarfaraz, Member Social Sector & Development at the Planning Commission, Government of Pakistan
• Amala de Silva, Professor, University of Colombo 

Universal Health Coverage (Sustainable Development Goal 3.8) requires not only access to essential health services for all but also financial protection – that no one experiences financial hardship when using the healthcare they need. While health service coverage was improving steadily prior to COVID-19, financial hardship from out-of-pocket medical spending remained pervasive. The pandemic affects financial protection through a variety of channels like reductions in household and public incomes, new health spending needs, and increased forgoing of care. This session explores these channels conceptually and empirically: After a brief introduction to financial protection indicators, the session will present global and regional trends in financial protection prior to COVID-19 and use new data and analysis to assess the pandemic’s impacts on out-of-pocket spending and the forgoing of care for financial reasons. Subsequently, panelists will provide perspectives on policies to improve financial protection during the pandemic and beyond.

June 14^th

08:00-08.30 EST : Opening Remarks 

08.30-09.30 EST : Plenary Session 1 – AHFF Introductory Session: Setting the Scene

Recording: English | French

Speakers: 

• Kara Hanson, Professor, London School of Hygiene and Tropical Medicine
• Joe Kutzin, Head of Health Financing Unit, World Health Organization 
• Christoph Kurowski, Global Lead of Health Financing Global Solutions Group, World Bank 

This is an introductory session led by Kara Hanson, Chair of the Lancet Global Health Commission and Christoph Kurowski, Global Lead of the Health Financing Global Solutions Group, World Bank

09:30-10.30 EST : Coffee Break 

10.30-11.30 EST EST : Plenary Session2 - Funding PHC in the time of COVID-19.

Recording: English | French

Meeting docs: Background Note | Presentation

Speakers: 

• David Evans, World Bank  
• Iryna Postolovska, Senior Health Economist, World Bank
• Mai Farid, Assistant Minister of Finance, Egyptian Ministry of Finance
• Mariana Mazzucato, Chair of the WHO Council/Professor in the Economics of Innovation and Public Value/Founding Director on the Economics of Health for All/University College London /UCL Institute for Innovation and Public Purpose.
• Ousmane Diaby, Director of Study and Projects, Ministry of Public Health, Cameroon 
• Ben Akabueze, Director General, Budget Office of the Federation, Nigeria
• Nick Carroll, Technical Assistance Advisor, International Monetary Fund 
• Katie Malouf Bous, Senior Policy Advisor – Public Services | Oxfam International

This session will present the most recent data on health spending, showing the growing rifts across countries in their capacity to invest in health. The discussion will also focus on policies that can result in greater funding for PHC, including such exploring questions as: Should countries be able to borrow more to increase government spending? Could countries enforce a minimum 20% tax on companies without encouraging international companies to relocate? In countries where health is now less of a priority, how should the relationship between Ministries of Health and Finance be reconsidered? Do the health sector and donor financing communities have any quick wins that could effectively drive more resources to PHC?

11.30-13.00 : Lunch  

11:45-12:45 : [Lunch event by invitation only] Africa Regional Partners Meeting

13:00-14:30 : Side Event -2 - From Performance-based Financing (PBF) to Strategic Purchasing of PHC Services

Recording: English | French

Speakers: 

• Ellen Van de Poel, Health Financing Lead, World Bank 
• Eeshani Kandpal, Senior Economist, World Bank 
• Hamis Colquhoun, Health Financing Consultant, World Bank 
• Dr. Stephen Banda, Director of Policy, Planning and Health Economics, Ministry of Health and Child Care, Zimbabwe 
• Dr. Oritseweymimi Ogbe, National Primary Health Care Development Agency, Nigeria  
• Thiane Gueye, Coordinator of the Health Economics Unit and President of the Women’s Association, Ministry of Health and Social Action, Senegal

Improving purchasing of PHC has long been a policy priority across LMICs. With support from donors, many countries have been experimenting with PBF as a mechanism to get more results from the available financing. A vast body of evidence around the impact of such schemes shows that indeed flexible financing and accountability at the lower levels of the health system are important to drive up utilization, but also questions the need for the fee-for-service mechanism and highlights issues of sustainability. Public financial management systems often do not easily allow for more output-based financing of PHC services, which creates challenges for integrating the key aspects of PBF schemes into the government system. At the same time, the capacity and experience generated through PBF schemes offer an opportunity to push forward the necessary reforms to move towards a more integrated strategic purchasing of PHC services. 

This session will lay out the evidence base around PBF, the challenges and opportunities it creates for moving towards more integrated financing, and illustrate how key components of PBF can be integrated into government systems. 

14:30-15.00 EST : Coffee Break 

15:00-16:30 EST : Side Event 3—Allocating Budgets for PHC: Using all the available tools to protect resources through to the frontline

Recording: English | French

Speakers: 

• Kara Hanson, Professor, London School of Hygiene and Tropical Medicine  
• Cheryl Cashin, Managing Director, Results for Development  
• Prof. Edwine Barasa, Director, Nairobi Programme, & Head, Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Kenya  
• Dr. Eduardo Gonzalez-Pier, Senior Technical Director Health Financing HP + Program, Palladium Global Group, Mexico  
• Carla Lopez Castaneda, Director Health Financing, Last Mille Head, USA 
• Linda Vanoto, Country Director of Accelerator Ghana, Results for Development 

Increasing expenditure on PHC starts with allocating more resources to PHC, and then protecting these resources so they reach frontline providers.  Resource allocation processes take different forms in different systems, depending on whether budgeting processes are centralized or decentralized.  But in all systems there are pressures for resources to drift upwards and away from PHC.  Three sets of policy tools are available to direct resources to PHC – budget formulation, budget execution (including provider payment) and service design.  This session will explore countries’ experience of using these different policy levers and the system capabilities need to deploy them effectively.  The session will begin by outlining the challenge of increasing budget allocations for PHC.  The three sets of policy tools will be presented, together with some evidence of how they have operated in different settings.  Panelists will be invited to reflect on how these tools have been deployed in their countries, with a focus on identifying the challenges to implementing them and how they have strengthened health systems and PFM capacity to enable redirecting resources towards PHC. 

June 15^th

8:00-9:30 EST : Plenary Session 3 - Making Output- and Population-based Financing Work in Budget Systems

Recording: English | French

Speakers: 

• Tim Williamson, Senior Governance and Public Sector Specialist, World Bank 
• Moritz Piatti, Senior Economist, World Bank 
• Dr. Sarah Byakika, Commissioner Planning, Financing and Policy, Ministry of Health, Uganda 
• Associate Prof. Pichenda Koeut, Director of Payment Certification Agency, Cambodia  
• Prof.Edwine Barasa, Director, Nairobi Programme, & Head, Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Kenya  
• Mark Blecher, Chief Director, South African National Treasury 

This session will present and debate practical steps on how to transition toward blended and consolidated provider payment frameworks for PHC in various Public Financial Management (PFM) settings. The session will address questions of balancing flexibility and controls in expenditure management, enhancing provider autonomy, developing public finance capacity, including the role of ICT, and the consolidation of funds flows towards a strategic orientation of PHC payment frameworks.  

09.30–10.00 EST : Coffee Break 

10:00–11:30 EST : Plenary Session 4-Paying for Essential Medicines for PHC

Recording: English | French

Meeting docs: Background Note | Presentation

Speakers: 

• Dr. Tessa Edejer, Acting Director of Health Systems Governance and Financing, World Health Organization   
• Lombe Kasonde, Senior Health Specialist, World Bank   
• Anna Fenchak, Deputy Head of National Health Service, Ukraine 
• Dr. Lydia Dsane-Selby, Former Chief Executive, National Health Insurance Authority, Ghana  
• Lily Kresnowati, Director of Health Service Assurance, Indonesian Agency of Social Security Administrator on Health Program (BPJS Kesehatan), Indonesia  
• Dr. Firass Abbiad, Minister of Public Health, Lebanon  
• Dr. Dominique Baabo Kubuya, National Coordinator of PDSS Health Systems Strengthening Project, Ministry of Health, Democratic Republic of Congo

This session will explore the available evidence on medicine expenditures as part of PHC across countries, drawing on the Lancet Commission’s work, as well as the impact of medicine purchases on financial catastrophe and impoverishment. The discussion will also consider strategies to reduce either the need for people to pay for medicines as part of their first-line treatment or the cost of these medicines (price and volume). It will also examine possible improvements in the supply chain along with debates about some of the WHO Council on the Economics of Health for All’s more controversial recommendations designed to increase the availability and the cost of new technologies in lower-income settings.

11.30-13.00 : Lunch 

11:45–12:45 : Lunch event: Indonesia’s Progress Towards UHC: A Single Payor’s Perspective on the JKN Program

Recording: English

Speakers:

• Somil Nagpal, Senior Health Specialist, World Bank 
• Lily Kresnowati, Director of Health Service Assurance, Indonesian Agency of Social Security Administrator on Health Program (BPJS Kesehatan), Indonesia  
• Mahlil Ruby, Director of Planning, Development and Risk Management, Indonesian Agency of Social Security Administrator on Health Program (BPJS Kesehatan), Indonesia  
• Daniel Dulitzky, Regional Director for Human Development-East Asia, World Bank 
• Christoph Kurowski, Global Lead of Health Financing Global Solutions Group, World Bank

13:00–14:30 EST : Side Event 4 — Open and Inclusive Processes for Financing UHC

Recording: English | French

Speakers: 

• Dr.Tessa Edejer, Acting Director of Health Systems Governance and Financing, World Health Organization   
• Professor Alex Voorhoeve, Head of Department and Professor in Philosophy, Logic and Scientific Method, London School of Economics and Political Science 
• Dr. Lydia Dsane-Selby, Former Chief Executive, National Health Insurance Authority, Ghana  
• Dr. Eduardo Gonzalez-Pier, Senior Technical Director Health Financing HP + Program, Palladium Global Group, Mexico  
• Oyebanji Filani, Commissioner, Ministry of Health, Nigeria   
• Dr. John Kinuthia, Senior Program Officer, International Budget Partnership Kenya  
• Ingvar Theo Olsen, Global Health Lead, Norad, Norway

Primary care is the foundation of resilient, equitable, and high-performing health systems. The recent Lancet Global Health Commission on financing PHC underscored the importance of people-centered PHC while highlighting PHC to be consistently under-resourced. Decision-making processes about prioritizing and financing PHC need systematic investment.  Frequently, people lack a voice in shaping these decisions. Moreover, critical decisions in health financing, such as allocation of resources between various types of services (primary care vs high technology interventions) or decisions modifying user fees or provider payment methods, are often made through opaque processes with weak evidence base. At worst, this contributes to inequitable decisions driven by self-interest of those in power. However, even when decisions taken through such secretive processes are well intended and are in line with good practices, it is likely that they will meet with resistance and non-compliance.

Building on the work led by the World Bank and presented in the Third Annual Universal Health Coverage Financing Forum (2018), the session presents a new report Fairness on the Path to UHC: Durability and Trust in Health Financing Decisions (working title).

14:30–15.00 EST : Coffee Break 

15:00–16:30 EST : Side Event 5 — The Political Economy of Financing PHC

Recording: English | French

Speakers: 

• Dina Balabanova, Professor, London School of Hygiene and Tropical Medicine  
• Susan Sparkes, Health Economist, World Health Organization 
• Nouria Brikci, Research Fellow in Health Economics, London School of Hygiene and Tropical Medicine  
• Triin Habicht, Senior Health Economist, World Health Organization   
• Dr. Wangari Ng’ang’a, Senior Health Advisor, Presidential Policy and Strategy Unit, Executive Office of the President, Republic of Kenya   
• Rozita Halina Binti Tun Hussein, Director of Planning Division, Ministry of Health, Malaysia 
• Esther Dweck, Professor, Federal University of RIo de Janeiro, Brazil 
• Alison Mhazo, Technical Advisor, Ministry of Health, Malawi

Effective and equitable financing of PHC requires explicitly considering the constantly evolving social, political, and economic conditions in a context - or the political economy of a country, in conjunction with technical factors. Political economy analysis includes three interdependent domains: the politics, the social conditions, and the economy of a country. In this session, we will look at each domain in turn, and discuss how engaging with these can support effective and equitable PHC financing and its successful reforms.  

17:30-19:30 : AHFF Reception

June 16^th

8:00-9:30 EST: Adam Wagstaff Memorial Lecture

Recording: English | French

Speaker:

• Prof. Justice Nonvignon, Head, Health Economics Programme, Africa Centres for Disease Control and Prevention, Ghana
• Juan Pablo Uribe, Global Director of the Health, Nutrition and Population Global Practice  
• Owen O'donnell, Professor, Erasmus University Rotterdam 
• Mario Vera-Fernandez, Professor of Economics, University College London 
• Radhika Jain, Lecture in Health Economics, University College London

Since 2020 the AHFF has held the Adam Wagstaff Memorial Lecture in honor of Adam Wagstaff, research manager at the World Bank, professor of economics, mentor, and associate editor of the Journal of Health Economics. During this year’s session, chaired by Juan Pablo Uribe, Global Director of the Health, Nutrition and Population Global Practice, awardees of the Adam Wagstaff Award (AWA) for Outstanding Research on the Economics of Healthcare Financing and Delivery in Low- and Middle-Income Countries, established by IHEA, will be invited to participate. Winners for the AWA 2020 are Giancarlo Buitrago and Radhika Jain.

10:00–11:30 EST : Plenary Session 5- Financing Comprehensive PHC and Q&A

Recording: English | French

Meeting docs: Presentation | Background Note

Speakers: 

• Ahmed Elsobky, Deputy Minister of Health and Population and Chairman, General Authority of Healthcare (GAHC), Egypt
• Christoph Kurowski, Global Lead of Health Financing Global Solutions Group, World Bank 
• Oyebanji Filani, Commissioner, Ministry of Health, Nigeria   
• Dr. Mahlil Ruby, Director of Planning, Development and Risk Management, Indonesian Agency of Social Security Administrator on Health Program (BPJS Kesehatan), Indonesia  
• Tamar Gabunia, First Deputy Minister, Ministry of Internally Displaced People from the Occupied Territories, Labor, Health and Social Affairs, Georgia   
• Carolina Casullo, National Director of Health Systems Strengthening at the Ministry of Health, Argentina  
• Dr. Liisa-Maria Voipio-Pulkki, Chief Medical Officer and Senior Adviser in the Permanent Secretary’s Cabinet at the Finish Ministry of Social Affairs and Health, Finland

Drawing on a first set of case studies, this session will highlight the scope, trade-offs, and priorities among comprehensive PHC activities from a bottom-up health system perspective as well as identify the local organizations and institutions responsible for their delivery. The session will also examine the financing and financing arrangements in different contexts for these activities and organizations and look at how these can be strengthened to attain a well-functioning, comprehensive PHC. 

11:30–13:00 EST : Lunch 

11:45–12:45 EST : Lunch event : Hot Topics in Immunization Financing

Recording: English

Speakers:

• Kent Ranson, Senior Economist, Health, Nutrition and Population Global Practice, World Bank, Switzerland 
• Lizna Makhani, Manager, Gavi, Switzerland 
• Sarah Alkenbrack, Senior Health Economist, Health, Nutrition and Population Global Practice, World Bank, USA 
• Ulla Griffith, Senior Advisor in Health Economics, UNICEF, USA 
• Prof. Justice Nonvignon, Head, Health Economics Programme, Africa Centres for Disease Control and Prevention, Ghana
• Helen Saxenian, Senior Fellow, Results for Development 
• Dr.Meerjady Sabrina Flora, Additional Director General, Directorate of Health Services, Ministry of Health and Family Welfare, Bangladesh

13:00–14:30 EST : Side Event 6-Health Taxes

Recording: English | French

Speakers:

• Toomas Palu, Advisor, World Bank 
• Dr. Evan Blecher, Economist, World Bank   
• Mai Farid, Assistant Minister of Finance for Economic Justice Board Advisor for the Universal Health Insurance Authority, Egyptian Ministry of Finance  
• Dr. Eduardo Gonzalez-Pier, Senior Technical Director Health Financing HP + Program, Palladium Global Group, Mexico  
• Dr. Tessa Edejer, Acting Director of Health Systems Governance and Financing, World Health Organization   
• Adanna Chukwuma, Senior Health Economist, World Bank 
• Ceren Ozer, Senior Economist, Domestic Resource Mobilization Unit, World Bank  
• Alan Fuchs, Senior Economist, Poverty and Equity Global Practice, World Bank

About 50 LMICs will not recover economically to pre-pandemic levels before 2026 putting at risk governments’ ability to finance essential expenditures, including health.  Public debt globally is expected to be 11% of GDP higher compared to pre-pandemic levels requiring larger set-asides for debt servicing further constraining effective fiscal space.   This is all in the context of countries still responding to a pandemic, having to invest in strengthening health systems for resilience and preparedness, and recover lost gains in making progress towards SDG3 and UHC.  Stepping up and spending 1% more of GDP on PHC as called on by UHC GMRs will be difficult. This session will explore the feasibility of health taxes on tobacco, alcohol, and SSBs as an option to simultaneously expand governments’ fiscal space and improve health outcomes. Expanding fiscal space includes increasing tax revenues and reducing expenditures related to tobacco, alcohol, and SSB use (e.g., healthcare, public safety, etc.). Earmarking of revenues for health may be viable in some jurisdictions and may also be important to increase political viability and/or public acceptability. 

15:00 – 16:30 EST : Side Event 7—Sustainable and Gender Equitable Capacity Building for Health Financing in Africa

Recording: English | French

Speakers: 

• Prof. Justice Nonvignon, Head, Health Economics Programme, Africa Centres for Disease Control and Prevention, Ghana  
• Oludare Bodunrin, Acting Director-of Strategic Purchasing Africa Resource Centre, Amref Health Africa, Kenya  
• Associate Prof. John Ataguba, Executive Director, Africa Health Economics Association (AfHEA)   
• Eva Pascoal, Health Systems Advisor, World Health Organization 
• Matiko Riro, Regional Technical Advisor, Health Financing, Clinton Health Access Initiative (CHAI) 

The skills and human resources required to perform health financing and health systems functions are growing more and more complex. In some areas and countries, approaches to strengthening capacity and training remain heavily reliant on external funding and expertise and have not been sufficiently sustainable and grounded in locally-defined needs and resources. There is a need for a robust understanding of the skills gap, career paths, and appropriate educational, training, and mentorship models to fill these gaps. Filling gaps means not only producing more expertise in diverse areas from health economics to management to data science but addressing gender equity in key areas.

This session will be a roundtable discussion including invited participants, primarily Africa-based academic, government, and regional organizations, to explore the challenges and potential solutions to strengthen country-level and regional capacity in a sustainable way by creating an alliance of regional actors.

June 17^th

*These sessions are by invitation only

9:00-11:00 EST : Development Partners Session 1

This workshop for partners, donors, and other key stakeholders will focus on furthering collaboration and coordination around the PHC financing agenda. In particular, this in-person event will bring together members from GAP, the Sustainable Finance for Health and the PHC accelerators and policymakers.

11:30–13:00 EST : Development Partners Session 2

Case studies from Pakistan and Nigeria