How can a government ensure that resources devoted to health are used efficiently and effectively? Which performance-based incentive is really providing the desired outcome? How responsive are health policies to the actual needs of its target community? The Health Finance and Governance (HFG) project was launched by USAID in 2012 to help answer these questions. It is a five year- 209 million dollar global project to improve health finance and health governance in partner countries. The end goal is to improve health outcomes and access to health care, as well as generate evidence on the most efficient improvements to health management.

HFG works on five broad topics relating to financing health projects: transparency and accountability, pricing and management, development of evaluation metrics, and capacity building. Perhaps the single most important factor in dealing with these issues is that local, regional and cultural aspects contribute to the problems and the solutions. No one solution can fit all countries or even all target populations within one country. Let us consider just one example of HFG’s work.

In 2013, the Kyrgyz Republic had a tuberculosis (TB) incidence rate of 141 for every 100000 people. It is among the countries suffering from the most high multi-drug resistant TB (MDR-TB) burden in the world, yet TB detection rate at 66 percent, and drug susceptibility testing coverage, at 25 percent is still low. The WHO cites poor coordination of TB data management, insufficient oversight of treatment and monitoring of adherence to treatment, and non-compliance by patients and health providers to the prescribed antibiotic regimen as well as poor infection control as causes for rampant prevalence of TB and the spread of MDR-TB.

In the 1990s, the Kyrgyz Republic transitioned its general hospital system to case-based financing, where funds are provided to a hospital based on the previous years bed occupancy levels. This incentivized hospitals to increase hospitalizations, which not only is not always required leading to ineffective use of funds, but also exposes the patient to an infection-rich environment where depressed immune systems can acquire secondary, drug resistant infections.

The HFG assisted the Kyrgyz Republic to transition to a financing system that is based on the number of patients treated. Under this model, the hospital would receive a set fees for complicated MDR-TB cases and a lower fees for less complicated cases. This kind of financing structure also stimulated hospitals to require bacterial confirmation of the disease as opposed to a more subjective clinical diagnosis, which would reduce the number of cases treated in error. To complete this transition successfully, the government had to be fully involved to ensure that finances saved by reduced hospitalizations would be reinvested to provide better support for TB outpatient services like patient transportation, supplies, and social support.

In this region, this kind of approach integrates well with more standard approaches of launching rapid diagnostics like the work done by the National TB program and TB Reach, or providing access to new antibiotics like the End TB Erogram run by Partners In Health, Medecins Sans Frontieres, Interactive Research and Development and UNITAID. There is still a long way to go and a lot of gaps to fill. As about 44 percent of the financing for TB projects in Kyrgyzstan comes from foreign aid, assistance in mobilizing domestic resources can make health projects more sustainable. This would parallel the work of HFG in Nigeria where it is working to increase the resource mobilization capacity to support HIV/AIDS treatment.

When the various arms of the government work effectively with each other and with private sector and donor organizations, inefficiencies and wastage in development projects can be resolved. However, the first step remains identifying these gaps and designing novel solutions to fill them. When the HFG completes its term in 2017, a full measure of its successes can guide further development decisions.

– Mithila Rajagopal

Sources: HFG, Medecins Sans Frontiers, StopTB, WHO, The World Bank
Photo: USAID