Are African governments in the driver’s seat when it comes to health financing policymaking?

A review published today in  Global Health Research and Policy explores whether governments have ownership of the policy making process in health financing in Sub-Saharan Africa and what exactly this ownership means. Here to discuss this and the influence of external donors in health financing policies is author of the review, Lara Gautier.

Universal Health Coverage (UHC) has recently become very popular in international forums: the 2016-approved WHO development agenda consecrated UHC as Sustainable Development subgoal 3.8. Thus, many of the “old” health financing policies get re-framed in the language of UHC. One question that may arise is whether national governments actually embrace the concept and decide to implement strategies that will achieve this (almost sacred) goal.

As I started my career as a junior professional in global health in West Africa, something caught my attention: the relationship between foreign donors and African governments. In many situations, my assessment was that there was something problematic with this relationship, something that somehow impeded the success of interventions.

Too many times I was witnessing international projects being implemented with little consideration for the public system in place or the people’s needs. I was witnessing inadequacy between what foreign donors (NGOs, private foundations, as well as international organizations and bilateral donors) were offering and what would actually make sense on the field.

Once, I saw a renowned international NGO recruiting community health workers before sending them to rural and remote villages. However, these CHWs were not originally from these areas: they came from the city. Most likely, their ability to integrate in communities and do a proper job would be undermined by this simple fact. I was not judging – there are good intentions behind this apparent mismatch – but simply realizing that it was worth investigating further. And so I embarked on the PhD adventure, in the field of health systems financing.

Governments in the driving seat?

One of the reasons I chose to specialize in this domain was that I thought this would be an area where governments would definitely have a say. Governments had to be in the driver’s seat because they would certainly care what sort of financial model would better provide healthcare in the whole country.

We chose to do a rapid review of what ownership actually implied for countries when decisions were made.

They would care because: 1) their budget is always tight (yes, tighter than ours) and 2) their popularity partly depends on the health status of their population. Idealists – myself included – would add to these self-regarding motives a genuine will to provide better and more accessible healthcare to populations. And this would, in turn, contribute to legitimize their power (some readers will probably think of Foucault at this very moment).

So I started investigating ownership of the policy making process in health financing. The problem was that, I was not at all convinced by the word “ownership”, which to me perpetuated – again – the representation systems of external donors. In the introduction of this article, we attempt to explain why the term, which got paired with other words (country, national, etc.), is problematic.

To depoliticize the word, we chose to do a rapid review of what ownership actually implied for countries when decisions were made. We came up with the following indicators of government ownership: political commitment by demonstrating leadership at the highest levels of government, effective engagement of technical levels of government, ability to coordinate international donors and partners’ support within public bodies, and national mobilization of domestic resources to finance the policy in the long term.

UHC involves many aspects (e.g. human resources for health, quality of healthcare), but we decided to focus on financing policies aiming at achieving UHC in Africa. The momentum was right, as several African countries had just undertaken major health financing reforms. We reviewed ownership of policymaking processes for three main health financing policies: user-fee exemption, health insurance, and results-based financing. Our review retrieved 35 papers, 24 of which showed mixed government ownership (i.e. there were indicators of ownership at some policymaking stages but not all).

We also found evidence that both government ownership and donors’ influence can successfully coexist.

Interestingly, when results demonstrated some lack of government ownership, we noticed that donors did not necessarily play a role: other actors’ involvement was contributing to undermining government-owned decision-making, such as the private sector. We also found evidence that both government ownership and donors’ influence can successfully coexist.

The results of our review show that, instead of pushing for new financing policies, donors should shift to strengthening the State’s coordination and domestic funding mobilization roles, together with securing a higher involvement of governmental (both political and technical) actors.

Short bio: Lara is a global health researcher currently enrolled as PhD student at School of Public Health (ESPUM) and Public Health Research Institute (IRSPUM) at Université de Montréal, and Paris Diderot University’s Centre d’Etudes en Sciences Sociales sur les Mondes Africains, Américains et Asiatiques (CESSMA). She coordinates the REALISME Research Papers collection.

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