Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions. From a contextual standpoint, these factors relate to favourable economic and political environments for domestic systems to prioritize coverage for donor-supported interventions. Clear and transparent transition processes also enabled a smoother transition. How the donor-supported initiatives and services were organized within the context of the overall health system was found to be critically important, both before and during the transition process. This includes a targeted approach to integrate, strengthen and align key elements of the governance, financing, input management and service delivery arrangements with domestic systems. The findings of this analysis have important implications for how both donors and country policy makers can better structure external assistance that enables sustained coverage regardless of the source of funding. In particular, donors can better support sustained coverage through supporting long-term structural and institutional reform, clear co-financing policies, ensuring alignment with local salary scales and engaging with communities to ensure a continued focus on equitable access post-transition.

Normalizing the political economy of improving health.

Problem: Political economy factors are important in determining the adoption and implementation of health policies. Yet these factors are often overlooked in the development of policies that have the potential to influence health. Approach: Political economy analysis provides a way to take into consideration political and social realities, whether at the community, subnational, national, regional or global levels. We aim to demonstrate the value of political economy analysis and to promote its wider use in technical programmes of work. Local setting: We provide examples from across a range of World Health Organization areas of work, including participatory governance, health financing, health taxes, malaria prevention and control, capacity-building and direct country support. Relevant changes: Existing examples of how political economy analysis can be incorporated into technical support demonstrate the variability of this analytical approach, as well as its potential to support policy progress. Applying political economy analysis within the specified programmes of work has enabled more contextually relevant technical support to enhance the likelihood of advancing countries' health-related objectives. Lessons learnt: Embedding political economy into technical work has many benefits, including: enhancing voice and participation in health policies; supporting the adoption and implementation feasibility of technically sound policies; and building capacity to incorporate and understand political factors that influence health-related priorities.

Will the Quest for UHC be Derailed?

COVID-19 has shocked all countries' economic and health systems. The combined direct health impact and the current macro-fiscal picture present real and present risks to health financing that facilitate progress toward universal health coverage (UHC). This paper lays out the health financing mechanisms through which the UHC objectives of service coverage and financial protection may be impacted. Macroeconomic, fiscal capacity, and poverty indicators and trends are analyzed in conjunction with health financing indicators to present spending scenarios. The analysis shows that falling or reduced economic growth, combined with rising poverty, is likely to lead to a fall in service use and coverage, while any observed reductions in out-of-pocket spending have to be analyzed carefully to make sure they reflect improved financial protection and not just decreased utilization of services. Potential decreases in out-of-pocket spending will likely be drive by households' financial constraints that lead to less service use. In this way, it is critical to measure and monitor both the service coverage and financial protection indicators of UHC to have a complete picture of downstream effects. The analysis of historical data, including available evidence since the start of the COVID-19 pandemic, lay the foundation for health financing-related policy options that can effectively safeguard UHC progress particularly for the poor and most vulnerable. These targeted policy options are based on documented evidence of effective country responses to previous crises as well as the overall evidence base around health financing for UHC.

Financing Common Goods for Health: A Country Agenda.

Collective financing, in the form of either public domestic revenues or pooled donor funding, at the country level is necessary to finance common goods for health, which are population-based functions or interventions that contribute to health and have the characteristics of public goods. Financing of common goods for health is an important part of policy efforts to move towards Universal Health Coverage (UHC). This paper builds from country experiences and budget documents to provide an evidence-based argument about how government and donor financing can be reorganized to enable more efficient delivery of common goods for health. Issues related to fragmentation of financing-within the health sector, across sectors, and across levels of government-emerge as key constraints. Effectively addressing fragmentation issues requires: (i) pooling funding and consolidating governance structures to repackage functions across programs; (ii) aligning budgets with efficient delivery strategies to enable intersectoral approaches and related accountability structures; and (iii) coordinating and incentivizing investments across levels of government. This policy response is both technical in nature and also highly political as it requires realigning budgets and organizational structures.

Political Economy Analysis for Health Financing Reform.

Health financing reform is an inherently political process that alters the distribution of entitlements, responsibilities and resources across the health sector and beyond. As a result, changes in health financing policy affect a range of stakeholders and institutions in ways that can create political obstacles and tensions. As countries pursue health financing policies that support progress towards Universal Health Coverage, the analysis and management of these political concerns must be incorporated in reform processes. This article proposes an approach to political economy analysis to help policy makers develop more effective strategies for managing political challenges that arise in reform. Political economy analysis is used to assess the power and position of key political actors, as a way to develop strategies to change the political feasibility of desired reforms. Applying this approach to recent health financing reforms in Turkey and Mexico shows the importance of political economy factors in determining policy trajectories. In both cases, reform policies are analyzed according to the roles and positions of major categories of influential stakeholders: interest group politics, bureaucratic politics, budget politics, leadership politics, beneficiary politics, and external actor politics. The strategic responses to each political economy factor stress the connectedness of technical and political processes. Applying the approach to the two cases of Turkey and Mexico retrospectively shows its relevance for understanding reform experiences and its potential for helping decision makers manage reform processes prospectively. Moving forward, explicit political economy analysis can become an integral component of health financing reform processes to inform strategic responses and policy sequencing.