Health financing in fragile and conflict-affected situations: A review of the evidence
Bertone, Maria Paola
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Witter, S., Bertone, M. P., Dale, E. & Jowett, M. (2019) Health financing in fragile and conflict-affected situations: A review of the evidence [Working Paper]. Geneva: World Health Organization.
WHO has well-developed guidance for the development of health financing policy, which supports progress towards universal health coverage (UHC) and overall health system goals. Most recently, a series of health financing guiding principles have been proposed, based around the different functions of health financing policy (Kutzin et al., 2017; McIntyre and Kutzin, 2016). The key messages in these guidance documents centre heavily on the importance of public finances, and the role of government in using those finances in the best way to strengthen their health system and maximise progress towards UHC. Fragile and conflict affected states (FCAS) present a growing challenge for achieving UHC and other developmental goals. In this paper, we examine core features of FCAS settings, which centre on deficits in capacity, legitimacy and security, and what this implies for health systems, but more specifically for health financing and in relation to the key messages and policy guidance currently offered by WHO. We explore common health financing constraints and opportunities and how policies have responded to these. These are summarised in Table 1. Our data analysis has shown that, as would be expected, FCAS countries have significantly higher out of pocket expenditure, external dependency and health-related impoverishment. They also have lower mean government expenditure on health in relation to wider government expenditure and total health expenditure. However, much of this is driven by the tendency of FCAS to be low income; when stratified, there are fewer clear differences at low income levels, whereas external dependence and impoverishment remain significantly higher for upper-middle income FCAS, perhaps indicating the effects of shocks. Conflict-affected countries within the FCAS grouping show similar patterns but more accentuated, with less external support and lower overall expenditure on health. Chronic FCAS countries (those in this category for more than five years) showed similar patterns to the wider group. Trends analysis shows some improvement in FCAS performance on health financing indicators over recent years, but from generally lower starting points and with regional variations. In terms of UHC coverage, FCAS have lower performance for all income levels. There are substantial challenges for health financing in FCAS settings but considerable ingenuity has also been shown in addressing them, albeit often externally driven. It is also important to highlight that many models have been developed and road-tested in FCAS settings – approaches such as performancebased contracting and PBF emerged to a large extent out of the need to innovate in FCAS and have since been applied in wider contexts. The literature highlights that crises often lead to innovation, and that innovations can leave a longer legacy (the issue of path dependency), which reinforces the need to use crises well.