Barbara McPake

Health after conflict – Rebuilding the system 13th December 2016Wellcome Trust, London

• A focus on the interaction between health systems, financing policies, poverty and conflict• 2 components:• Reanalysis of household survey data aiming to identify

impact of health financing policy changes on households’ access to health care and expenditure patterns pre-conflict, during conflict and post-conflict (as permitted by data).• Life history study of older heads of poor households

and their health care use before, during and after conflict, focusing on relationships between health seeking behaviour, expenditures on health care, conflict and health and poverty experiences.

Background on health financing research

Background on health financing research

Results from survey reanalysis: Sierra Leone

• Free Health Care Initiative (FHCI) introduced in 2010 had relatively small effects. • The proportion of children who accessed care

with payment increased, but not children’s utilisation of care overall, and use of informal sources of care may have decreased.• Use of maternal health services increased

substantially but was not sustained over time – most likely due to supply side constraints.

Results from survey analysis: Cambodia

• Complex mix of financing policies• the formalisation of user fees in public health facilities • the introduction of health equity funds (HEFs), both

government and donor funded, which fund the exemption of poor households from fees

• vouchers for pregnant women to cover costs of maternal care in public health facilities

• community based health insurance • contracting arrangements by which public subsidies are

allocated by a contract rather than budgetary process. • First attempt to consider them across all their combinations• Overall, rollout of schemes associated with general reduction in

OOP by poor• Equity funds associated with reduced OOP; vouchers more

modest effect but stronger when combined with other schemes.

• Effects increase over time

Results from survey analysis: Uganda

• Withdrawal of user fess from all public health facilities occurred in 2001• Over 90% of population of Northern Uganda in

internal displacement camps at that time – not directly affected• We studied impact of population’s return from

camps after 2006 on household budget and health expenditure patterns• Food consumption increased. Overall utilisation of

health services did not change significantly but shift from formal private services to informal private services and public services, especially for poorest

Life history findings: country specific issues

• Zimbabwe: post-crisis period after ‘dollarization’ reduced households’ capacities to cover costs – fees in hard currency; inadequately funded social protection; under-funded public services push people to private sector• Uganda: poorly functioning public system with frequent

drug stock-outs and physical access challenges means frequent use of drug shops and small private clinics if resources available• Sierra Leone – wide regional variation in cost experience

- catastrophic outcomes from both non-use and expensive but ineffective use of health care• Cambodia: schemes to support poor households access

affordable health care help, but fail in the end to protect households from poverty becauase of chronicity of problems and less than full subsidy

Conclusions/Recommendations 1• Life histories explain and contextualise household survey

analysis; Both sets of findings largely consistent• Health financing policies targeted at removing or reducing out

of pocket health expenditure are essential interventions in processes that drive and maintain poverty at household level, many of which originate or were exacerbated by conflict.

• Health financing policies limited effectiveness in addressing processes of poverty because: • not fully implemented – e.g. formal fees replaced by informal

ones.• inadequate funding to support effective service delivery: health

utilisation and expenditure redirected to private and informal health providers

• insufficient coverage of ancillary costs • incentives for the health workforce to ensure access to effective

services and non-discriminatory treatment of exempted populations are inadequate

• unfunded exemptions result in an impossible choice for service providers between honouring exemptions and maintaining service provision.

Conclusions/Recommendations 2• Problems result from piecemeal rather than systemic

understanding of intervention. In conflict affected settings, capacity and staff experience limitations are particularly important

• Longer term consideration of impact needed: not discrete before/after effect but one that evolves. Attention needs to be paid to how to reinforce policy intentions in the processes of health system management and support over the long term.