According to the WHO report, public expenditure in health decreases as a percentage of total public expenditure in the presence of donor aid, and does not increase in line with fiscal growth. But what does this mean in relation to improving population health and economic productivity? This answer to this question is not easily extracted from the report. In fact, the single methods page gives little detail as to data provenance and how it was analysed – necessary requisites of any academic paper submitted for peer-reviewed publication. The document also reports patterns of spending as proportional to total investment, which in the absence of absolute figures can be misleading, though the authors do recognise this as a caveat within the report. The underlying assumption here seems to be the myopic belief that the healthcare sector should be taking up an ever-greater share of public expenditure in all circumstances. But what does analysing and tracking percentage of public expenditure on health really tell us about whether monies are allocated appropriately and systems are operating efficiently?

The WHO report focuses heavily on the question of fungibility and whether development assistance crowds out domestic funding for the healthcare sector. However, an argument can be made that investing in areas such as infrastructure, sanitation, or education may be an even better use of scarce country resources than healthcare, since it has a direct impact on alleviation from poverty and an indirect positive impact on health. There is perhaps some value in a country trying to ensure access to safe drinking water and adequate sanitation before investing in the rotavirus vaccine for all its children. Indeed, a recent study examining the fungibility of development assistance in Tanzania found that fungibility of external funds was in fact beneficial to the country’s development, with evidence suggesting that the ‘displaced’ funds were reallocated towards education. It is obvious that the opportunity cost of spending finite, scare resources in LMIC unwisely has implications beyond health, so fiscal elasticity in this context is not necessarily detrimental, but potentially beneficial.

In recent years, a number of econometric studies have been carried out to address the question of the fungibility of development assistance. However, results of these analyses have been shown to be highly sensitive to the methods used, and are usually based on weak and divergent data sources.

The real problem with the question of fungibility and how to capture and analyse it, is that we’re asking the wrong questions. What we should be asking is not where the money is going, but instead ‘are those monies allocated appropriately and spent efficiently to maximise value?’, where allocative efficiency is dependent on the presence of effective priority setting and governance. Answering this question involves looking beyond the expenditure databases at priority setting mechanisms within particular countries and what financing and governance models can be made to work best for donors and, more importantly, for countries, in their quest to improve health and wellbeing for their populations. Indeed, the emergence of pay for performance incentive schemes and Development Impact Bonds is evidence of a growing trend towards results-based health financing (for more information, see Centre for Global Development’s extensive literature on the potential and pitfalls of these kinds of financing models).

Aside from the substantial technical, statistical, and data quality issues of fungibility-focused econometric studies, it is very difficult to extract the answer to the ‘So what?’ question of how to make things better. One way to address this question experimentally is to design a well-structured, responsive, and flexible co-financing system which facilitates a shift of focus on fungibility to productivity gains. Such a system was recently put forward by Morton and Colleagues, which is founded in the assumption that a list of ‘best buys’ can be relatively easily generated for countries. These high-benefit and low cost interventions could be paid for by the country and more costly interventions higher up the list could be paid for by donors, either in full or as part of a cross-subsidy agreement. The question is then targeted at the point at which an intervention becomes cost effective, within the confines of the domestic budget, and whether donors should subsidise up to this point at the assumption (or agreement) that local policymakers will pay for interventions at the point at which they become cost effective for them. This kind of alignment of donor and local priorities has also proved successful in the form of sector wide approach to payments (SWAp), where recent analyses suggest that $0.52 more cents of domestic government revenues is spent in the health sector when health aid is channelled to settings where there is a SWAp in place. Such co-payment mechanisms focus more on a reciprocal relationship and open conversations between donors and local governments to enter into mutually beneficial contractual arrangements, which significantly reduces the importance of fungibility. To take the argument one step further, we should aspire towards non-siloed donor budgets which can look not only beyond vertical programs, but also beyond health towards pan social-sector relevance – then fungibility loses its meaning entirely.

As countries progress they should be establishing robust mechanisms for evidence-based priority setting to ensure that value is maximised for every rupee, peso or rand spent. Whether health spending as a share of public spending increases or decreases is of secondary importance to the question of whether money is spent wisely. In the context of a rapidly changing development assistance landscape, policymakers and donors alike should be focussing on the ‘so what’ question – what will the transition from external to domestic financing mean for health outcomes? How can donors and policymakers work together to facilitate a smooth transition? And how can domestic resources be most effectively prioritised to ensure best value health buys? The global health community needs to rise to the challenge and support policymakers across the world to spend their money better, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.

Laura Downey¹, Alec Morton², Kalipso Chalkidou^1,3

1 – Global Health and Development, Institute of Global Health Innovation, Imperial College London, London UK
2 – Strathclyde Business School, University of Strathclyde, Strathclyde UK
3 – Global Health and Policy, Centre for Global Development, London UK

The workshop narrative derived from the global need to develop UHC as a way to improve health, expressed in the SDG 3.8 “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The basis for the workshop was a document published by CGD on priority setting in health (1).

This 3 day workshop had the overall objective of scope out the content and process for developing guidance on HTA as a tool for reimbursement decisions. A specific deliverable at the end of the workshop was a document outlining:

1. Key issues that need to be tackled in the guidance
2. Insights and learnings from participants that can inform each of these issues, including where possible, identification of  “landmark”  documents and  countries examples of good/bad practice
3. Recommendations for research or data collection on information gaps.

The participants were invited based on their involvement in the Health Technology Assessment (HTA)/priority setting process in their respective countries, and a distinction was made between countries in different levels of development of HTA/priority-setting system (established or working towards UHC). There were representatives from South Africa, Chile, Thailand, the UK, the United States, the Philippines, Croatia, Norway, Switzerland, and other countries. The participants present worked in a wide range of organisation: HTA research – University of Wits and Indonesia, HTA agencies – NICE and HITAP, the Ministry of Health – Zambia, Chile and Vietnam, regional HTA networks EUnetHTA and HTAi, and global funders – BMGF, the UK DFID, GAVI and the Global Fund.

Over the three days, the participants listened to, participated in and prepared sessions on: the scope of work of an HTA mechanism; how are countries setting up HTA mechanisms; legal frameworks for HTA mechanisms; minimum capacities for HTA mechanisms; the role of regional and global partners and networks; criteria to be used at different stages of the HTA process and monitoring the effectiveness of HTA mechanisms. Alongside these sessions, breakout groups discussed questions as: steps and principles for HTA processes; what are the main considerations in landscape/context/mandate analysis and criteria and negative/positive lists of implementing HTA.

The workshop was a success, with a strong interest from the WHO to collaborate with iDSI in future work. IDSI and the WHO are discussing next steps, and there has been a strong interest from the participants to participate in the development of this document.

The agenda for the workshop is here

The workshop is free to attend. Participants will be selected by Indonesia’s HTA Committee and the WHO from select universities and relevant units within the Ministry of Health. Although the workshop has a targeted audience, anyone interested in learning more about the workshop or HTA in Indonesia can contact Dr Dewi Indriani by emailing indrianid@who.int. The event flyer is available here.

We look forward seeing you there!

NICE International visited Geneva to meet with senior colleagues from UNITAID, the Global Fund and GAVI.

During the meetings, we discussed the importance of demonstrating value for money of investment at both the central and national levels, especially as an increasing number of countries are transitioning to a less donor-dependent status.

A growing number of countries are requesting support from iDSI on how to spend their own money on healthcare technologies and services. Global disease and technology-specific funding channels and donors have a responsibility to support capacity building (through institutions, people and data). This will ensure countries are able to take on the burden of continuing to provide (where appropriate) technologies and services that are financed, procured and often delivered by foreign parties.

We will continue to work with our partners and interested parties to help demonstrate the value for money of healthcare investment from the country perspective – a value proposition very different from conventional Return On Investment behind much of current thinking.

The meetings were organised by the US-based Results for Development.

Cuba’s reputation for producing dedicated health workers who are prepared to work in difficult or remote health contexts is well known and was profiled by Jose Luis de Fabio, Director of the Pan American Health Organisation in Cuba. Since the 1970s Cuba has been a major producer of health workers with a commitment to international solidarity in health and provides doctors to countries facing severe shortages of health workers. The selection process for entry to Cuban medical education focuses on social skills and competencies as much as academic ability which has helped overcome the mal-distribution of health workers, common in most countries, which leave major  gaps in service provision for poor and marginalised populations.

But perhaps the Cuban experience is not all it seems.  Jimmy Volmink, Dean of the Medical School of Stellenbosch University in South Africa laid out the advantages and disadvantages of a long-standing scheme that trains African students in Cuba with the aim of providing doctors for rural areas. Volmink highlighted the culture shock that awaits rural black African students in Cuba, the language problems, the lack of internet to enable easy communication with relatives back home, and problems of re-integration with South African trained students when they return home for ‘top-up’ courses on malaria,   HIV/AIDS, neonatal infections – preventable diseases that are not common in Cuba.  One returning student said: “if you buy a cat, don’t expect it to bark!”  The culture shock and the process of adaptation experienced by these students may be essential components that makes the Cuban approach so powerful.  Incubating Cuban approaches within Africa – a potentially more logical and less disruptive plan – but without the experience in Cuba may not work so well.

These optimistic and pessimistic views of the transferability and utility of Cuban medical education arise because of different contexts and ways of implementing the Cuban approach – which is very flexible and is modifiable depending on the resources available.  All systems of medical education produce ‘pluri-potential’ doctors who may become family doctors, eye surgeons or psychiatrists. So the cat-dog analogy doesn’t work for me.  Neil Squires, Deputy Director, Public Health England, asked whether the global shortage of family doctors and an imperative for universal health care, would leverage medical schools to focus their core curriculum on graduating functional family doctors.  John Ashton, President of the Faculty of Public Health, described such a scheme operating in the rural mid-west states of USA.

Jim Campbell, Director of WHO’s Health Workforce Department, described the WHO Initiative on transforming and scaling up health professionals’ education and training which has compiled regional case studies.  These provide a substantial evidence base from which to work.  WHO’s commitment to universal health coverage and the new sustainability development goals that will do away with targets, replacing them, for example, with zero acceptance of neonatal and maternal deaths and 100% access to primary care provide compelling reasons for solving the primary care workforce crisis.  The massive growth in health care in high income countries is likely to suck markedly large flows of doctors from low income countries.[Crisp & Chen, 2014] Global action to create primary care doctors and community health workers on an industrial scale is needed now to offset workforce crises in primary care, which in turn provide fertile soil for epidemics of preventable communicable and chronic diseases.

Evaluations of the Cuban model have been conducted in the past but questions of selection of students, training of faculty, competences at graduation, impact on distribution and retention of doctors in disadvantaged and rural communities need to be answered to provide better evidence for policy making.  A DfID funded policy programme grant has been awarded to support Cuban, African and UK collaborative research on the Cuban approach.  In the UK, NICE International, Public Health England and LSHTM are involved.  The research aims to answer these questions:

• Does the Cuban system of medical education result in more equitable distributions of doctors? And in stronger retention of doctors in rural and disadvantaged communities?
• Are doctors trained in the Cuban model equipped with an appropriate set of skills and competencies for primary care? Are they better equipped than doctors trained in conventional ways?
• What lessons can we learn for health professional capacity building from a development perspective? And what can we learn for the NHS here in England?

Medical schools should be capable of assimilating and retaining the lessons learned over the last 40 years: redesigning selection processes to improve access for disadvantaged students; early and long-term contact with patients and their families; shifting teaching into primary care; integrated core training of doctors, nurses and other health professionals. [Frenk et al, 2010]  General Medical Councils may make accreditation more difficult for highly innovative education but they are not the barrier.  Deans of medical schools have more room for initiating change as demonstrated by the Training for Health Equity network (THEnet) and other networks, one of them arising in Africa,  the Consortium of New Southern African Medical Schools.  Once again we have to “turn the world upside down”, asking rich countries to learn these lessons from Cuban medical schools which show how doctors with vision, resilience, relevant competencies and the motivation to work with the most disadvantaged people can be created.

Prof Shah Ebrahim, Honorary Professor of Public Health at LSHTM, is collaborating with NICE International, Public Health England, PAHO and the Cuban Ministry of Health on the DfID-supported project on Cuban medical education model for Africa.

References

Nigel Crisp, Lincoln Chen. Global supply of Health Professionals. N Engl J Med 2014;370:950-7

Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58