A HSR 2018 satellite session, which will focus on health financing towards Universal Health Coverage (UHC), has received funding from Sida, working on behalf of the Swedish Parliament and Government. The full day session is co-hosted by the Clinton Health Access Initiative, Sida and iDSI.

1. The satellite session will feature policy makers from Sub Saharan Africa sharing their experiences developing and implementing policies and reforms to make progress towards UHC. What are you hoping will come out of this session?

Low and middle-income countries are facing a very similar set of health financing challenges and implementing related reforms. There are many success stories and practical experiences to be shared from the people currently implementing reforms on the ground.

We are hoping that this session will contribute to strengthening the knowledge exchange between the decisions-makers from Low and middle-income countries in how to best address common challenges and learn from each other.

We will focus on how priority setting, defining basic health services, resource allocation and strategic purchasing can be applied to make progress towards UHC, including essential sexual and reproductive health and rights (SRHR): What do we pay for, which services and for whom, and how do we pay it? How do we make the difficult choice of prioritising certain services above others and how do we ensure that services are delivered in a sustainable and equitable way? How do we ensure key services such as SRHR are included and specific needs of for example adolescents and young women are not left behind.

2. Can you tell us more about the facilitators and panellists that will be part of the satellite session?

We are bringing together leading researchers, government officials and policy representatives from Asia and Sub-Saharan Africa that have on the ground experience in developing and implementing policies.  This includes government representatives from countries Sida is supporting, with technical assistance from the Clinton Health Access Initiative (CHAI) in health financing reforms (Ethiopia, Rwanda, Malawi, South Africa, Eswatini, Zambia).

We believe this mix of people will make for interesting discussions. We will also open up the floor after each sub-session for an audience of international attendees.

3. Investment in sexual and reproductive health and rights in Sub-Saharan Africa is major part of Swedish development cooperation. Can you tell us some more about the work of the regional team based in Lusaka and Sida’s approach?

Sweden has a feminist foreign policy and SRHR is a top priority for Swedish Development Assistance. Approximately 60 per cent of our official development assistance for health is directed towards SRHR. The regional team works on SRHR to advance the continental and regional agenda for sexual and reproductive health and rights through supporting legal and policy reform, expanding access to essential SRH-services, changing social norms around gender and sexuality, as well as advancing accountability for regional commitments. The team has partnerships with regional economic communities such as the Southern African Development Community (SADC) and East African Community, parliamentary fora such as SADC Parliamentary Forum, the UN including the United Nations Population Fund and WHO, research institutes and civil society networks. Our work with CHAI on health financing is an important part in advancing SRHR in sub-Saharan Africa. Access to SRHR services, under a model for UHC, requires a transparent and inclusive discussion on how resources are prioritised and what services to include in basic packages based on the best available evidence. For us, UHC is based on the principle that basic health services should be provided to all. If these principles are adhered to, SRHR services become naturally prioritised.

Sida’s commitment to SRHR is likely to remain for the foreseeable future. Therefore we believe in establishing long-term partnerships with organisations that can contribute to normative change in the region.

4. What do you enjoy most about your role?

My position gives me a good overview of regional SRHR issues and a chance to see how different structures and processes are related. Thanks to that overview, I have a unique opportunity to connect partners and key actors to initiative and networks where synergies can be created. The HSR 2018 satellite sessionis a good example of connecting people to achieve more. Personally, I am very happy to be part of the promotion of SRHR-interventions as a natural and integral part of basic health care packages and UHC since these services respond to common and often recurring needs in the population and therefore must be included in public commitments.

5. If you weren’t in the global health, what would you be doing instead?

Living in Sweden I would probably work for a health provider with Lean production and quality assurance or in a purchaser–provider organisation defining volumes, cost levels and quality standard of health services in assignments to health providers, both public and private. Irrespective of which job, I would make sure I was involved in organisational and operational development since it really matters “how” services are provided and what results you get for your money.

Conference delegates can attend ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’. Find out more at www.healthsystemsresearch.org/hsr2018

1. You are a panel member in the sub-session, ‘Design of Health Benefit Packages’ during the HSR 2018 satellite session on Health Financing for Universal Health Coverage (UHC), co-hosted by Clinton Health Access Initiative, the Swedish Government and iDSI. What do you believe your experience will bring to the discussion?

I have been coordinating the process to define benefit packages in preparation for implementation of National Health Insurance (NHI) in South Africa for the past two years. NHI is our version of UHC and aims to address historical inequalities by bringing the public and private sector into a unified national health system. As I have been responsible for health programmes in South Africa for the past 10 years this was a good fit. I think I will benefit as much from the discussion as I think I can contribute based on our experiences in trying to design benefits in a rather complex environment – with a large private health sector and many medical insurance companies and administrators.

2. What are Health Benefits Plans and why are they important?

Health benefit plans define the services that will be available within a health system and should cover all levels of care, from community based services through to highly specialised care. This is important for at least two reasons: (a) certainty on what services are offered; and (b) ensuring that these services are funded.

3. What have been the challenges in development of the benefits package in South Africa?

An initial challenge has been the wide range in standards and guidelines relating to service delivery in South Africa not just across the public and private sector, but also across disease areas. We are addressing this as a priority to ensure a common understanding of acceptable quality of care prior to costing. Other challenges include: (a) availability of data, including epidemiological data, (b) limited or fragmented health technology assessment capacity in the country; (b) political pressure to include all services currently available – even in the context of limited resources; (c) and the designing of a transparent process by which to prioritise services and revise the package over time.

4. If you weren’t in the healthcare field, what would you be doing instead?

Human rights lawyer!
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Conference delegates can attend the session, called ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’.

Find out more at www.healthsystemsresearch.org/hsr2018

The ‘setting priorities fairly’ event is the first of its kind for Sub Saharan Africa (SSA), with the main event opened by Ghana’s Minister for Health, Kwaku Agyemang-Manu. How important is it for representatives from SSA to share knowledge to optimise the impact of health spending?

The prospect of HTA in SSA is promising, with an increasing number of countries planning to use HTA as a priority-setting tool to promote Universal Health Coverage (UHC). In the light of this, it is crucial that SSA countries share experiences (however little) to learn from each other.

What can attendees to your workshop session on case studies of how Health Technology Assessment can inform decisions on cost-effectiveness expect?

Attendees can expect to learn what has been done already, especially in the case of Ghana and how that applies to their specific country context.

Ghana was the first Sub Saharan African country to introduce a National Health Insurance Scheme (NHIS) and has long standing commitment towards achieving UHC, of course, there is no “one-size-fits-all” approach to UHC, but what is on Ghana’s agenda?

Ghana’s road to UHC through the NHIS has been brave and bumpy, with key challenges relating to financial sustainability. However, given the political support – from all sides of the political divide – the future of the NHIS is bright. A key approach is expanding enrolment through innovative strategies including group enrolment, enrolment of prison inmates etc. In addition, there are efforts to boost the financial status of the NHIS while removing other bottlenecks to promote UHC. A key way forward is re-visiting the Primary Health Care agenda to strengthen close-to-client services and implement provider payment mechanisms that reduce overall service costs and enhance sustainability of the scheme. The overall improvements in the economy could boost fiscal space for health and fast-track attainment of UHC.

You have led on a number of research projects on health economics and policy in Ghana, Botwsana, Kenya, Malawi and Nigeria – what has been your biggest achievement?

My joyous moments (which I see as achievements) are when I see that recommendations from a previous study I was involved in are evaluated and implemented. A typical example was when the Ministry of Health and World Health Organization in Botswana accepted the findings and recommendations of our study on efficiency and begun planning to implement.

What do you enjoy most about your role?

I enjoy seeing my former students in decision-making roles, applying some of the things they learnt. I also enjoy being involved in discussions and networking (with networks such as the platform that iDSI provides) that are directly relevant for evidence-informed policy making in low- and middle-income countries, particularly efforts that benefit Ministries of Health.

If you weren’t a health economist, what would you be doing instead?

I would have been a geomorphologist, studying earth formations.

Registered delegates can attend the workshop Justice will feature in, ‘Introduction to Health Technology Assessment’, from 1pm on 26 September 2018, as part of Setting priorities fairly: sustainable policies for effective resource allocation in Africa.

The US capital was the setting for three days of meetings and events to mark UHC Day and the release of ‘What’s In, What’s Out: Designing Benefits for Universal Health Coverage’.

IDSI’s time in DC kicked off with a Global Health Initiatives meeting attended by representatives from the Gates Foundation, World Bank, Givewell, the Center for Global Development (CGD), PRICELESS South Africa, the UK Department for International Development (DFID), Clinton Health Access Initiative (CHAI), Japan International Cooperation Agency (JICA), the Joint Learning Network (JLN), Tufts Medical, Disease Control Priorities (DCP), the Health Intervention and Technology Assessment Program (HITAP), the Norwegian Institute of Public Health (NIPH) and Gavi the Vaccine Alliance.

During the meeting iDSI, CHAI, JLN, NIPH and Tufts Medical Centre showcased their initiatives and the concentration of their work including their successes, focus countries and potential future opportunities.

Amanda Glassman

Attendees then heard from Global Development Funders’ representatives: David Wilson from the Gates Foundation, Julia Watson from DFID, James Snowden from GiveWell, Adrien de Chaisemartin from Gavi, Naina Ahluwalia and Somil Nagpal from World Bank and Yosuke Kobayashi from JICA; with all agreeing each partner group is carrying out valuable efforts in the bid to expand and improve healthcare globally.

Tuesday 12 December was the celebration of UHC Day around the world. A sold-out event at the CGD offices saw presentations from iDSI Director Professor Kalipso Chalkidou, CGD Chief Operating Officer Amanda Glassman, Professor Karen Hofman from PRICELESS, Waranya Rattanavipapong from HITAP, iDSI Board chair Professor Tony Culyer and a keynote speech by Dr Mark McClellan.

Copies of ‘What’s In, What’s Out’ were available for attendees to take away and Amanda Glassman explained how the creation of an explicit health benefits plan is an essential element in creating a sustainable system of UHC. With limited healthcare budgets comes tough decisions for policymakers, along with the many facets of governance, institutions, methods, political economy and ethics that are needed to decide what’s in and what’s out in a way that is fair, evidence-based, and sustainable over time.

Dr Mark McClellan

At the heart of Dr Mark McClellan’s keynote address was opportunities for greater value for healthcare spending – specifically, the ‘accountable care’ model, which sees providers held jointly accountable for the cost and quality of care for a defined population of patients.

Dr McClellan, a doctor and economist, said: “There is more healthcare can do than ever before, however this means rising costs in healthcare. The value of healthcare can be improved by developing and implementing evidence-based policy solutions.”

The importance of sharing data and creating interoperability to understand health outcomes within an accountable care system was also put forward by Dr McClellan, who provided Nepal as an example of success in utilising remote personal health tools, telemedicine and lower-cost sites of care: “In Nepal a simple process of patients’ texting in information can result in a visit to their homes by community care workers and a potential prescription of antibiotics. Investment in these modest but effective interventions can also gather useful metrics in the form of electronic health records. We need to move from ‘siloed’ data to data that provides intelligence about our populations.”

Waranya Rattanavipapong

HITAP’s Waranya Rattanavipapong presented on building research capacity for UHC in Southeast Asia and told of how analysis by HITAP revealed Indonesia could save 90% of its insulin budget. Waranya said: “Indonesia has a current budget of $18 million per year for insulin. Tens of millions more than necessary is being spent on modern insulins to treat diabetes despite evidence cheaper products work just as well. Our analysis revealed switching from insulin analogue to human insulin and negotiating to Thai prices ($2 for human insulin and $9 for insulin analogue, compared to $20 for human insulin and $22 for insulin analogue in Indonesia) could save 90% of the budget.”

Professor Karen Hofman detailed the strides South Africa has taken towards promoting the health of the population by passing a bill to implement a tax on sugar-sweetened beverages. Professor Hofman, who proudly sported an ‘I am #sweetenough’ t-shirt supporting the sugar tax, focused on fiscal levers in South Africa and the positive impact they have had in the past: “After the increase in the excise tax on cigarettes, sales reduced between 1993-2009 by one third and per capita consumption decreased by 50%. With 25% of teenage girls in rural areas overweight in South Africa, the time is now for translating evidence on sugar to policy. There will inevitably be push-back from various sources but the passing of the bill, which will be implemented in April 2018, is a powerful step forward.”

Professor Karen Hofman

Professor Tony Culyer rounded up the event and took to the stage to emphasise iDSI’s objectives to help low- and middle-income countries to transition from aid, develop skills to spend smarter and to increase access to quality healthcare so they can achieve UHC: “Our aim is to give LMICs capacity to produce policies that will have an impact of health. We wish to leave behind an endowment of expertise for LMICs to build better worlds for themselves.”

A recording of the ‘Better Decisions, Better Health: Practical Experiences Supporting UHC from around the World’ event is available on the CGD website (1 hour 32 minutes).

UHC Day, commemorated each 12 December, is the anniversary of the first unanimous United Nations resolution calling for countries to provide affordable, quality healthcare to every person, everywhere. The United Nations Sustainable Development Goals, that all UN Member States have agreed to, try to achieve UHC by 2030. This includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Professor Tony Culyer

In order to provide a platform for South African policymakers to engage with local and international experts around this area, a Policy Dialogue was organised in South Africa by iDSI partners in March 2017. The Policy Dialogue followed a workshop entitled “Designing and Adjusting the Health Services Package for Universal Health Coverage in South Africa”.  Representatives from the South African Treasury and the NDoH engaged with experts from South Africa, the United Kingdom and Thailand to discuss topics related to a Health Services Package (HSP).

After a discussion of key challenges, the participants agreed upon some important next steps to address these. Firstly, clarity on the budget envelope and financing of NHI in the context of the relationship between national and provincial-level decision making and resource allocation (fiscal federalism) is required. Due to the large variability of quality, transparency and availability of clinical guidelines, there is a need for a dedicated unit responsible for coordinating clinical guidelines. It is also important to build understanding of and commitment to evidence-based medicine especially amongst clinicians, and to strengthen the local ownership of clinical guidelines. Clear criteria need to be developed for ‘value for money’ such as a cost-effectiveness threshold. Establishing a national health technology assessment (HTA) unit will provide the technical and analytic input required to inform evidence based decision making for the NHI and HSP. Furthermore, priority topics for HTA need to be identified. Lastly, formal public engagement processes and collaboration with a wide range of stakeholders is important for the successful and appropriate implementation of an HSP.

To read the full report click here.

The white paper was revised and gazetted as the National Health Insurance Policy in June of this year. You can access the policy document here.

Professor Karen Hofman explains how a sugary beverage tax could reduce diabetes and obesity in South Africa in her recent lecture at Imperial College London.

As part of a Global Health & Development lecture, Professor Karen Hofman discussed the research evidence that informed the tax on sugary beverages in South Africa, to be promulgated in 2017/2018; and the political economy of potentially introducing such a levy.

A growing body of evidence indicates that excessive sugar consumption is driving epidemics of obesity and related non-communicable diseases (NCDs) around the world. South Africa (SA), a major consumer of sugar, is the most obese country in Sub Saharan Africa, and 40% of all deaths in the country are NCD related. Several fiscal, regulatory, and legislative levers could reduce sugar consumption in SA. These low cost instruments are a “Best Buy” and could save lives from obesity related diseases, save health care costs and generate revenue. This talk will focus on a sugar sweetened beverage (SSB) tax first proposed by the SA Treasury in 2016. Professor Hofman presented some of the analysis that informed key SA policymakers, the cost of inaction and discussed lessons learned from other middle income settings.

This event was chaired by Professor Franco Sassi, Professor of International Health Policy and Economics.

Here’s some of our Twitter highlights from Professor Hofman’s lecture…

These are the problems that the Guide to health Economic Analysis and Research (GEAR) resource aims to answer. It is an online platform dedicated towards helping LMICs’ academics, researchers and economic evaluation practitioners worldwide conduct high quality, policy relevant healthcare research. GEAR compiles and resolves gaps arising from methodological issues in the conduct and the use of economic evaluations. The resource will explore the issues in the conduct and the use of these evidences, potential solutions to the issues and future research questions to address these issues but also will.

The site is based on tiDSI) supported. The paper, “Identifying Priority Methodological Issues in Economic Evaluation in Low- and Middle-Income Countries: Finding the Holy Grail,” details the results of a literature review and questionnaire used to survey national and international experts, academics, public health officials, and relevant stakeholders on economic evaluation methodological issues. The respondents ranked the issues by order of priority or importance per their own experiences working in their country and/or abroad as well as propose some solutions that they consider relevant. These results were analyzed, triangulated with research questions proposed by the research team based on t he solutions nominated, and presented on the database. The prioritization of methodological problems and finding their solutions will lead to methodological research for improved tools in the conduct of economic evaluations. This database, which is funded by the Bill and Melinda Gates Foundation through the iDSI grant and the Thailand Research Fund, complements this work and provides immediate solutions to researchers’ needs.

On March 8, 2017, in Pretoria, South Africa, the website was launched to a group of partners
from the International Decision Support Initiative (iDSI) and LMIC partners from Colombia, Ethiopia, Ghana, Indonesia, South Africa, Switzerland, Tanzania, Thailand,      the UK, the US, Malawi, and Zambia. Prof. Anthony Culyer, a British Economist and Emeritus Professor of the University of York, opened the proceedings and likened it to the Professor Arrow’s founding of health economics. A short introductory and training workshop followed, showing that participants found the GEAR useful and helpful. Finally, Dr. Suwit Wibulpolprasert, former Chair of the National List of Essential Medicines in Thailand, closed the program by bidding the participants to bring the GEAR out to the world, to provide solutions to all researchers in need.

Day 1 was opened by Francis Ruiz of GHDG and Prof. Karen Hofman of PRICELESS and focused on sharing experiences of the use of evidence in policy making in different country contexts: South Africa, Thailand, China, India, Cambodia and the UK. Participants at the workshop included academics from South Africa, representatives from the South African Department of Health, the WHO, and the Bill and Melinda Gates Foundation (BMGF), plus the country representatives who spoke about their specific contexts. In exploring the ‘HTA journeys’ of different countries, participants learnt about the main drivers for HTA, the factors involved in establishing a framework for HTA informed decision making (e.g. political will, legislation), and what HTA was used for. Netnapis Suchonwanich of HITAP, Thailand, and former Deputy secretary-general at National Health Security Office highlighted for example, that successful structures for incorporating evidence into policy can be established in resource constrained settings where there is a commitment to UHC. Indeed, HTA can be considered an important tool in ensuring the affordability of any universal benefits package devised.

Day 2 focused on a ‘deeper dive’ into the factors that need to be considered when establishing HTA ‘agencies’ with a focus on the ongoing work in establishing iDSI HTA hubs in China, South Africa and India. iDSI hubs are an important mechanism for making iDSI goals, particularly in-country support, more responsive, scale-able and sustainable. These hubs could also serve as centres of regional support. Each of the iDSI HTA hub centres are at different stages of development – it was announced for example at the meeting that the China hub would be launched next month. Damian Walker of BMGF highlighted the importance of taking an in-country focus to hub development, so that the necessary elements can be put in place to allow for effective regional support, as was demonstrated by the experience of Thailand’s HITAP, one of the core partners of iDSI.

Day 3 focused on identifying areas of further collaboration among all the participants represented at the workshop. Areas of cooperation included joint research, placements and study tours.

The full agenda for the workshop can be found here. All the presentations from day 1 and day 2 can be found here.

Please click here to download the Job description.

To apply, please forward your CV and a covering letter to llazarus@icon.co.za 

Closing date for applications is Thursday 30 June 2016

Quality improvement initiatives for reducing maternal mortality in the form of Quality Standards represent a cross cutting programme of work that will enable joint working on key activities while addressing a major health priority in south Africa. However, while Quality Standards have been used internationally to goo effect, it is imperative that any initiative is tailored to local need and context.

Addressing the above, on the 6th of April this year PRICELESS and iDSI organised a workshop with the topic “Maternal Care Quality Standards in the South African Context” in Pretoria, South Africa, led by Karen Hofman.

The meeting objectives were:

• to identify existing guidance and quality improvement initiatives in maternal health and seek coordination and potential synergies
• Learn about the experience of adapting NICE developed Quality Standards in Maternal health to the context of Kerala, India
• Explore the applicability of the Quality Standard approach to the South Africa Context.

During the workshop, topics were introduced by speakers from all over the world. The workshop started with an introduction by Karen Hofman. After, Carol Marshall talked about the current status and existing quality improvement initiative in South Africa and Bob Pattinson discussed the 2015 Maternal Guidelines. Dr Francoise Cluzeau (NICE International) gave an introduction to Quality Standards (QS) and Dr Vakkanal Pailey (Kerala Federation of Obstetrics and Gynaecology) spoke about Lessons Learned: Developing Maternal Quality Standards Adapting to Kerala, India. The group discussed whether Quality Standards could be adapted to the South African Context, identifying the scope of QS, the key stakeholders in this context and the proposed timeline.

The agenda and the slides can be downloaded below

Maternal QS meeting Agenda

Quality of Care Initiatives by Dr Carol Marshall
Maternal Care Quality Standards in the South African context by Karen Hofman
Implimenting Quality: An Introduction to Quality Standards by Dr Francoise Cluzeau
Quality standards in ob care : the right approach by Dr Vakkanal Pailey