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FHS at the 2nd Global Symposium on HSR: Blogging from the front lines



It may be stormy and snowy on the eastern seaboard of the United States, but in Beijing, China, the ginko leaves are starting to turn golden and it’s been a crisp couple of fall days. Members from across the FHS research consortium are gathering here this week to participate in the 2nd Global Symposium on Health Systems Research. According to their website, the symposium is ‘dedicated to evaluating progress, sharing insights and recalibrating the agenda of science to accelerate universal health coverage (UHC)’.

With nearly 1,900 participants registered to attend, we’re expecting the symposium to be very busy and for that main theme to play out in a variety of ways. FHS alone will be participating in a wide range of activities throughout, from the Emerging Voices pre-session, to various satellite sessions today, a stall in the marketplace and number of panels, presentations, posters and even a video presentation.

In particular, FHS will bring attention to the role of the private sector in health service delivery, how a complex adaptive systems (CAS) approach generates new insights to health systems functioning, promoting cross-learning among BRICS countries, effective mechanisms for building capacity for health systems research, and approaches to policy influence and research uptake.

We know that not everyone interested in these issues could be here in Beijing. As such, FHS researchers will be sharing their diverse perspectives throughout by offering opinions and reflections on the FHS blog. Please note that these blogs represent only the opinions of the authors. They do not necessarily reflect the position of FHS as a consortium, other researchers or partners within the consortium or of our main funders.

Presentations, videos and pictures will also be made available online, so stay tuned!


What if the world’s poorest obtain most development services from the ‘market’? 


[Editors note: This blog post originally appeared on IDS's Governance and Development blog, and has been reproduced on the FHS website with permission.]


Much energy is spent on debating whether services such as health, education and veterinary medicine, should be provided by the public or private sectors. But the answer to this question turns out to be irrelevant for most of the globe’s poorest.

Who pays for services in Low and Middle Income Countries?
Most of the severely disadvantaged people in the world live in poorly governed states in South Asia, China and Africa. In these and many other Low and Middle Income Countries (LMICs) formal and informal user-fees are pervasive in the public as well as the private sectors.  

True, much of Latin America, Taiwan, Malaysia, Thailand, Sri Lanka and Botswana have established effective government-run systems for health and other services that are not reliant on market relations, but these are not the places where most of the ‘poorest of the poor’ live.

Generally, someone who needs curative medical treatment, education, or veterinary care in most other LMICs will have to pay someone for it. For example:

  • In India less than 25% of rural health services are provided by government (and even with the latter usually involves informal payments). Likewise the non-state sector provides the overwhelming majority of curative services in Bangladesh.
  • Animal health services in tropical Africa moved from overwhelmingly free government provision before 1980 to almost universally compensated services by 1990, as is also true in India. Even when ‘free’ primary education is found in these countries, most often it involves payments for uniforms, supplies, and instructor tutoring.

So the distinction between ‘public’ and ‘private’ is more one of ownership and supervision, not of whether money is being exchanged. A market is present in both the ‘government’ and ‘private’ service sectors in these countries. It is more useful to look at variations in the market than in the formal attributes of the providers.

Are the poor getting what they are trying to pay for?
None of this is to say, that the poor don’t deserve subsidised services; they do. But sometimes subsidies benefit civil servants, rather than the poor. For example, government veterinary staff in India actually charge informally the same prices as private practitioners.

And even when the subsidies do reduce the costs to the poor, almost always payments by the recipients are not eliminated. Given this continuing reality, it is important to ask if the poor are getting what they are trying to pay for.

The poor living in poorly governed LMICs can and do invest modestly in the purchase of needed services and can be seen buying from higher cost providers. This is particularly true in the face of catastrophic events, especially if they have land or some other collateral asset. Nonetheless the quality of services offered to the poor in poorly governed LMICs is frequently seriously deficient.  

Tackling inequality of information on quality of services
The poor have more knowledge about the quality of the services on which they rely than is generally recognised. But in the purchase of professional services, those who are selling their expertise know more than their customers. When institutions are available to help overcome this information inequality, people are able to get better value from their purchases and are willing to buy more. This is called solving the problem of ‘information asymmetry.

In poorly governed societies a development priority is to build a set of institutions that enable quality in competence, effort and accountability to be rewarded in providers and signalled to consumers. In societies with high levels of governance, the state usually plays a central role in providing institutional solutions to the problems of information asymmetry.

In most countries with low levels of governance and poorly developed paths for public sector improvement it is unrealistic and counter-productive to expect government to be the sole provider of individualisable (‘private’) health and development services for the poor.

Granted, even in these settings the state will often want to play a role in planning institutional solutions by non-governmental actors to ensure the provision of services that have important ‘externalities’ (such as disease prevention, surveillance and control) with collective benefits.

But what might those solutions to the ‘information asymmetry’ problem in the delivery of essential individualisable services be? In a subsequent blog post I will scan the development literature for the lessons that emerge. 

For now, I stress that the world’s poorest are having to buy key development services from markets in both the public and private sectors and that those markets are unlikely to disappear any time soon. We therefore need to make those markets work to improve the quality and utility of what the poor are going to purchase. 

This blog draws on a paper currently under consideration with WORLD DEVELOPMENT -- Institutional Solutions to the Asymmetric Information Problem in Services for the Poor by David Leonard, Gerald Bloom, Kara Hanson, Juan O’Farrell, and Neil Spicer.



China’s Health care Reform: Towards “Health Care for All” 

BY Dezhi YU, Xuefei GU, Yunping WANG (China National Health Development Research Center)

[Editor's note: This piece originally appeared as an Editorial for the IHP newsletter, and has been reproduced here with their permission.]

China launched a new round of healthcare reform in 2009 with the overall goal to establish a basic healthcare system for all, and provide the people with safe, efficient, convenient and affordable health care services.

In the past three years, substantial efforts have been made and 850 billion RMB has been committed to invest in the following five priority areas: (1) accelerate the establishment of basic health protection; (2) set up a national essential drugs system; (3) improve the grass-roots health services delivery system; (4) gradually equalize public health services; and (5) pilot test public hospital reforms.

Evidence has shown that significant achievements have already been made in the reform of the urban and rural grass-roots health services delivery system, in terms of both facility construction and capacity building. Meanwhile, people’s financial access to essential health services has improved and the economic burden of disease has been reduced with the rapid development of a basic health protection system, composed of the New Rural Cooperative Medical Scheme (NRCMS), the Basic Medical Insurance scheme for Urban Employees (BMIUE), the Basic Medical Scheme for Urban Residents (BMSUR) and the Medical Assistance Scheme (MA) for urban and rural poor households. MA has helped to improve the equity in health services utilization and enhance the reimbursement level for poor households through subsidizing NRCMS premiums, paying costs below the deductible, cross-reimbursing, and providing immediate financial assistance for catastrophic costs.

By the end of 2011, more than 95% of the Chinese citizens were covered by this system. For the NRCMS enrollees, average financing has increased to 250 RMB per capita, while the out-of-pocket rate has dropped to 49.5%. The percentage of rural households residing within 15 minutes of a health facility increased from 75.6% (in 2008) to 80.8% (in 2011). Out- and in- patient health expenditure now increase by less than 7% in public hospitals annually (i.e. less than economic growth). The infant mortality and maternal mortality rates have declined from 14.9‰ to 12.1‰, and 34.2/100,000 to 26.1/100,000 respectively.

Yet, great challenges remain on the road towards “health services for all”. Typical challenges include: (1) compared with the increasing expectations of beneficiaries, the benefit package of the basic medical security system remains rather narrow and the reimbursement level is considered low; also, the insurance is not portable between provinces. The pooling fund should thus get the best out of every penny spent to ensure access to quality health services and prevent the risk of overspending with proper cost-containing measures and a payment system reform, as well as an appropriate policy on cross-government transfer payments. (2) Deepening the comprehensive reform of the grass-roots health facilities in terms of management mechanism, financing mechanism, drug supply system, personnel management and remuneration mechanism, and information system. A GP system also has to be established. (3) Accelerating the public hospital reform by innovating the management and service delivery pattern, establishing a corporate governance structure, changing the financing mechanism and incentives, encouraging the private sector to invest in the public hospital reform, etc.

In the next five years, the Chinese government is expected to make further progress towards a basic healthcare system for all, by improving the allocation of health resources and ensuring equity, to ultimately enhance the health status of the entire population.


An interview with Dr Kirsty Newman: Understanding evidence-informed policy


Dr Kirsty Newman, INASPAt the end of February, I travelled to Nigeria for the International Conference on Evidence-informed Policy Making. I've already posted some of my reflections on and takeaways from the conference, but while there I also had the opportunity to interview Dr Kirsty Newman, the Head of the Evidence-Informed Policy Making Programme at INASP.

As one of the organisers of the conference, she had a lot to say about the role of evidence in the policy-making process. Below are her answers to five questions I posed her around research, evidence use, and policy processes.

1.      What is your understanding of 'policy'?

Usually when I talk about policy I am thinking about public policy- in other words the decisions made by governments about what to do or indeed what not to do! It is important to realise that policy does not necessarily mean legislation.

I recognize that there are other types of policy too. For example, large non-governmental organizations such as the Red Cross or Oxfam make decisions on what to do that also can have a big impact on people's lives.

2.      Who are the stakeholders in the policy making process that should be targeted with research based evidence for policy influence?

I feel that too much energy is put into trying to influence Members of Parliament- these are sometimes seen as the only policy makers! It is important to realise that the executive arm of government as opposed to the parliament is usually the key driver of policy making. Although parliament has a role in scrutinizing policy, many parliaments are in reality quite weak. So for a start I would suggest thinking about the executive as well as the parliament. This might include relevant ministries but also para-statal or semi-autonomous agencies which sit below ministry level. I would also suggest looking at the staff who work within policy making institutions. These might include policy analysts, legislative drafters, advisors, researchers, librarians and so on. These people play a key role in providing information and advice to the high level policy makers and so it is very important that they are well informed.

3.      In what ways can researchers get the attention of these stakeholders with an aim of understanding their needs or constraints to using research for evidence informed policy making?

I believe that one of the key things that we all need to think about is that policy makers and their staff will never make use of research evidence if they don't understand what it is. Therefore, I think it is crucial that as well as pushing out research to them (supply) we consider how to build their capacity to understand, critically evaluate and use research (demand). This might involve training policy makers and their staff or simply taking the time to explain research concepts to them.

Given my own background in medical science, I am constantly surprised by how many people are making decisions on medical issues without even a basic understanding of key research concepts such as randomized placebo controlled trials. If you don't understand this method then there is no reason that you would think that a properly tested drug is better than a drug for which there is only anecdotal evidence.

4.      Do we have success stories to look at in terms of uptake of research evidence for policy making?

Last time I was in Nairobi, I was watching a local TV station and they were discussing herbal medicines. They had a Kenyan scientist on explaining how these medicines can be tested to see if they are really effective. Rather than relying on her status and just saying 'we are the experts so we can tell you what works', she was taking the time to explain concepts such as the placebo effect, confirmation bias etc. and explaining why rigorous research methodologies are needed in order to determine if a given drug really works. I was really impressed by this approach- it went far beyond what I would usually expect of a news channel in the UK.

I think the only way that policy making will ever be evidence-based is if the population understands research and demands policies based on sound evidence. So in a way I see this as a success story- or at least a step in the right direction. I think that if we put more effort into explaining what research evidence is and how it can help us to make better decisions, then we will achieve more evidence-based policy in the future.

5.      How best can researchers communicate their findings to policy makers?

Education, education, education! Of policy makers but also of the public. If they understand research they will be far more receptive to the findings you have to offer. If they don't understand research then you are just competing with all the other lobbyists to see who can shout the loudest!


Understanding the policy process: Reflections from the International Conference on Evidence-informed Policy Making


Picture a gathering of researchers and other stakeholders interested in evidence-informed policy-making. And to this gathering a question is posed: what are the three main roles of parliament? The ‘examiner’ distributes pieces of paper on which respondents should write the answers.

Well, that is the ‘exam’ which kick started the International Conference on Evidence-informed Policy Making at the end of February at Nigeria’s National Centre for Technology Management, which I attended.

While the task seemed simple, only one participant (who also happened to be a parliamentarian from Uganda) got all the three correct answers. That's legislation, oversight and representation, in case you wanted to test your own knowledge. I got two out of three having forgotten the obvious role of representation.

Such simple tasks remind us that sometimes we take many things for granted. For instance, up until the conference, a good number of participants -- including myself -- thought that in order to influence policy, members of parliament should be the main target of research evidence. But while members of parliament might be an ultimate target, they hardly have time and it is their clerks and assistants who do the lion's share of their research. Equally, I learned that furnishing the Parliament Library with research is invaluable. There may equally be a need to lobby the cabinet where the white papers are prepared before presentation to parliament.

I was in attendance at this conference as an observer on a mission to learn. As such, I took note of the above. When asked how he would want researchers to approach him with evidence, Ugandan legislator Obua Denis Hamson, who also chairs the Science and Technology Committee of Parliament, was concise in his response: “Probably the easiest way is to first give me a brief summary of your research findings. We can start from there.” What I got from this short and snappy reply was that researchers need to make the most out of research summaries and policy briefs.

The other thing I observed at this conference is that while 'evidence-informed policy making' has become a buzz word in international development, most of the work that has been done on this subject focuses on the 'supply side' (i.e. dissemination of research rather than the capacity to demand and use research from the policy side). Little has been done to understand both the incentives that drive policy makers to look for research information and their capacity to find and evaluate it. The only work around this area presented at the conference was done in Uganda with support from the UK Parliamentary Office of Science and Technology. But going by presentations about ongoing research funded by the co-organizers of the conference (International Network for Availability of Scientific Publications), substantial evidence on the demand side will be forth coming.

And with the final words of INASP’s Dr Kirsty Newman came the take home message. Researchers, when approaching policy makers, should not only use their research but a wide range of related evidence to argue their case.

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