Research for free health
Regina Keith, Global Health Advisor at Save the Children tells RealHealthNews why this is a critical moment for research on health financing.
The NGO Save the Children hoped to use Sri Lanka as a global model to show the success of free primary health care – and researched and reported their case thoroughly. Still the world didn’t notice. But they think strategically, and have new plans on how to turn research into action, with North-South “research coalitions” with Africa and Latin America getting to work as user fees are cut.
RHN:with the Institute of Policy Studies in Colombo you researched Sri Lanka’s success in bringing down child and maternal mortality – and reported your results in the document Bucking the Trend. But now you’re moving research on what you call “socially just financing” into Africa and Latin America, and bringing in Western academia – what’s going on?
Regina Keith: Did you know that in 1978 WHO’s Alma Ata declaration on primary health care, calling for health for all by the year 2000, built on what Sri Lanka was doing?
Today, Sri Lanka is still resource poor, with high malnutrition rates, but without high mortality in children or mothers. So we looked at how they achieved that. We concluded that one of the reasons was that they prioritized health, and education, free – plus food – at the point of service. Sri Lanka was one of the few countries that didn’t follow the 1993 World Bank model for economic growth – they continued with free inpatient and primary health care.
Now we aim to see if this model can work elsewhere. Several countries have ended (or are planning to end) user fees, and we want to use evidenced-based operational research to pilot alternate health financing mechanisms and measure what happens.
One interesting case study will be Bolivia – the new president, Evo Morales, has promised to turn their present approach upside down by unprivatising water services and making health services free at the point of access. They will use insurance: if you can buy insurance, you do; but if not, the government pays.
RHN:Have they been influenced in this by what they know and have learned about Sri Lanka?
RK: Certainly they have been influenced by Cuba, which has followed a social justice model, and reaped health benefits. However that’s a communist country, of course, so other things are different. We chose Sri Lanka as a case study as they have managed to achieve good health outcomes despite weak economic growth, high levels poverty and malnutrition, and even internal conflict [with Tamil separatists]. Even in the conflict areas, access to health and education is still free at the point of service.
So Sri Lanka could be a good model for Africa, where conflict is an issue in many countries. Although issues like transparency and gender equity are very different.
Donors like the UK’s Department for International Development (DFID) have been working with countries like Uganda and Malawi and Zambia to make health systems work for all through health sector reforms. In Uganda, health service utilisation more than doubled after abolition of fees, with an increasingly decentralised drug budget and staff salary increases.
We’ve also been looking at countries like Madagascar, which abolished fees during the war, and had a boom in the use of the health system – which dropped again once fees were reinstated. But now they say they can’t afford it. Then South Sudan is building a new set of policies, and does not want to use fees; but they too may not be able to afford free health care.
But last year the G8 group of rich countries pledged finance for countries wishing to abolish fees, with UK particularly strong on the negative impact of fees on the poorest.
RHN:Everything you’ve been saying is deeply political – there are strong positions for and against user fees. But for you, what has research got to do with it?
RK: We hope to work with some countries to support research coalitions – linking ministries, NGOs and academics – ensuring countries get technical support for evidence-based programmes for operational research.
There’s a big problem with the perception of aid effectiveness. If we can’t show that aid has been useful…[in the future it may be lost].
What we need to do is to find out if [abolishing use fees] works! Is it a model for Africa? Changes are happening now. We need to hit the ground running. The need is immediate. We need to get to districts now, to do research, to measure impact, while helping ministries to ensure that children are immunised against deadly diseases and protected against dying from treatable diseases like pneumonia and diarrhoea.
RHN:So you want to do operational research as the money goes in, and as policies are implemented.
RK: Exactly, and then see if the money’s getting where it should, because one of the big challenges is money not getting to where it needs to go.
We’ve just secured funding to support health systems in one state in Nigeria. Working with someone like His Excellency Dr Eyitayo Lambo – Minister of Health in Nigeria – who understands economics and research, as he demonstrated in your interview with RealHealthNews – could ensure that evidence – based programmes are rolled out in other districts. We’ll start in a district, and if it works in a pilot in that district (and Nigerian districts are massive, like countries inside a country), we could see if it could be transferred to the rest of the country.
To do that [at national scale] countries need a promise of long-term funding, with G8 countries following through with increased aid and debt relief. With technical support we may be able to change the present course for children in Africa and reach MDG 4.
RHN:And research, if it showed the pilot worked, could help to convince them…
RK: That’s why we’re trying to “operationalize” research in Africa. Take South Sudan, which has agreed they don’t want user fees. Can we research with them to build new policies and effective alternatives to fees? In countries like Tanzania, we’re looking at the systems they have right now, working with a national research institute, Research on Poverty Alleviation (REPOA).
Harvard University and other academies are also interested – as are donors. We want to study what changes in health financing mechanisms at district level are possible, in order to ensure the poor can access effective health services.
RHN:But if Sri Lanka was your model, aren’t there so many other positive factors there, that influenced their success, such as education levels? It’s not obvious it will work elsewhere.
RK: That’s why we need to do proper case studies in other countries! Take Botswana. In 1967, before they found diamonds, they decided to have free health and education. Then they struck lucky and the diamonds helped them to fund that. But they still have problems. Why? How do we overcome the bottlenecks and problems? That’s why we need to look at countries like that as case studies.
And take countries like Uganda, which took steps that have had a positive impact on health, but now face governance issues and electoral pledges, which could lead to regressive decisions being made.
RHN:What kinds of operational research do you want to see done?
RK: I’d like a mixture of ministries, communities, NGOs, national research institutions, and academic institutions and WHO. We need to address the present reality that sees less than 10% of research being spent on diseases of poverty – with less than 3% of that on health systems research. NGOs and civil society are often ignored in such coalitions. We need to combine NGO access to communities and strengths in qualitative research, with more normative research. We need to twin more institutions in the West with ones in the South.
And we will set up peer review panels, like you have at RealHealthNews. That panel would agree on the kind of baseline studies we’d do, read initial results, and help to put together an initial questionnaire, covering the breadth of issues and indicators we need to follow through. And they’d help with quality assessments mid-term and at the end, help to edit final reports and pull out the policy implications. And sometimes even come to the meetings! RW