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Towards UHC in Burundi – How to argue for “more” money ?

Towards UHC in Burundi – How to argue for “more” money ? . Simin Schahbazi | Burundi. Towards UHC in Burundi – Role of domestic funding ? ? . Government investment in health Who funds health in Burundi ? Who is covered ? On the way to UHC ? Steps on the way to UHC

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Towards UHC in Burundi – How to argue for “more” money ?

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  1. Towards UHC in Burundi – How to argue for “more” money ? Simin Schahbazi | Burundi

  2. Towards UHC in Burundi – Role of domestic funding ?? • Government investment in health • Who funds health in Burundi ? • Who is covered ? • On the way to UHC ? • Steps on the way to UHC • Innovative funding mechanisms • Challenges for dedicating domestic resources to health

  3. GOVERNMENT INVESTMENT IN HEALTH NOT REACHING ABUJA TARGET 10% of Government budget allocated to the health sector (2012) The health sector is increasingly dependent on donor funding

  4. WHO FUNDS HEALTH IN BURUNDI? Total health expenditure by source (2010) THE per capita: 29 USD(2010); 26 USD (2012) THE as % of GDP: 12% (2010), 9% (2012) Share of household contribution decreasedfrom 38% (2007) to 28% (2012) BUT: still serious equity concern as catastrophic health expenditures limit access for the poorest groups: 123 persons are pushedintopovertyeveryday

  5. WHO IS COVERED? 50% of Burundians are covered by some health insurance scheme schemes contribute to only 17% of THE (2012) Insufficient and fragmented coverage CAM (Public medical insurance): 20%, indigents: 1%, CBHI: 2%, Civil Servants: 6%, PHI: 1%, gratuité/PBF: 20% Schemes are highly underfinanced (CAM + indigents!) Hospitals increasingly indebted

  6. ON THE WAY TO UHC ? • Lessonslearnedfrom international experiences: • Politicalwillregarding UHC • Sufficientinvestment in health: most of the schemes are highlyunderfinanced • Progressive process: PBF OK but not CAM • Minimizing fragmentation and enhanceequity in pooling: high fragmentation • Reformisincludingdemand and offer of health services: quantity & quality ! • CAM: accelerator to achieve UHC ? • Strongpoliticalwill (MOH), high coveragepotential of informalsector if mandatory • Politicaldebate: Assistancemédicale vs. Assurance médicale • Indigents? 15-20% → subsidizing premiums ! (solidarityfund GOT+PTF ?)

  7. Since 2011: UHC Vision Recommendation of the health sector Revue Recommendation of the revue PBF/gratuité Situation Analysis started in Sep 2013; finalized in April 2014 Validation workshop with GOV, PTF, CS including reflections on on strategy options First draft of strategy 2014 ? - Institutional arrangements - Upcoming presidential elections 2015 !

  8. INNOVATIVE FUNDING MECHANISMS DISCUSSED IN BURUNDI ? • Diverting existing domestic resources to UHC • CAM, MFP • Commitments to HIV/AIDS, malaria, TB (mostly Global Fund ) • Commitments to multilateral health programmes(e.g. GAVI for vaccination) • Introducingefficiency and effectiveness • PBF • Collecting taxes and insurance contributions more efficiently • Reduction of fragmentation in pooling to expand redistributive capacity of prepaid funds • Improving financial management • Avoiding double payments (gratuité) • Creating new sustainable funds for UHC • Taxes on harmfulproducts: decisiondécember2013 →beertax (CAM) • Taxes on tabacco are discussed • … ?

  9. CHALLENGES FOR DEDICATING DOMESTIC RESOURCE TO HEALTH • UHC is theoretically priority on political agenda, BUT • Inadequate institutional arrangements hinder the commitment for domestic financing • Financial constraints: GDP 260 USD/capita (2012) • Challenges: macroeconomic constraints, poverty, galloping demography • Scope of action to maximize fiscal space is not very high but existent:

  10. THANK YOU! simin.schahbazi@giz.de

  11. PBF/gratuité 2006: exemption of user fees for pregnant women (delivery, services)& children<5 2010: scaling up performance-based financing (PBF) schemes into a national mechanism → Strategy: linking the PBF approach with user fee exemptions Advantages: • formalized channel for replacing the revenue from user fees at the facility level (incl. verification/validation system) • incentives for increasing quantity and quality of care → counterforce for the demotivation of health workers • Reducing administrative burden • GOT commitment (annual 1.4% of GGE) • Weakness: • Pervers effects and frauds • Problems of qualitymeasuring • Overlapwitchothermechanisms • Underestimatedprices for someindicators (delivery: 40USD) • Incertitude of PTF funding • Coverage: ≈20 % • utilization of health services in Burundi has continued to increase → strategy contributes to MDG 4 and 5 • BUT: PBF transforminginto a simple financingmechanism of the «gratuité » • Financing gap: 8 mill USD (2013) • Critical situation in raisingnumber of hospitals→ demotivation → Quality ↓

  12. Since 2011: UHC Vision Recommendation of the health sector Revue Recommendation of the revue PBF/gratuité Situation Analysis started in Sep 2013; finalized in April 2014 Validation workshop with GOV, PTF, CS including reflections on on strategy options • 4 options for a strategy (non-exclusive): • Maintain of schemes + compulsoryinsuranceformalsector + solidarityfund (indigents) • 2 schemes (formal, informal) + extended CAM+ + solidarityfund (indigents) • Schemeformalsector (compulsory)+ Extended CBHI – (Rwandian model) • Unique mechanism of SHP (Ghanian model) First draft of strategy 2014 ? Upcoming presidential elections 2015 !

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