Addressing health system fragmentation to improve efficiency on the road to Universal Health Coverage
Health programs are important channels to target health interventions and policies for specific populations or diseases, including for HIV and AIDS, Tuberculosis, Malaria, non-communicable diseases, immunization, among other priority health interventions. These programs have contributed to improvements in life expectancy, maternal and child mortality and improved health outcomes. However, there have been unintended consequences — for example, the creation of parallel service delivery, procurement, supply chains, information systems, planning and financing systems that operate separately from, or even outside of the purview, of the Ministry of Health. This fragmented organization is often compounded or even motivated by donor funding for specific conditions or priorities. Maintaining many discrete health programs is neither sustainable nor aligned with the goals of most public health leaders to progress toward greater health system equity, quality and efficiency.
As many countries are currently facing fiscal constraints and pressure to move away from donor dependency, now is the time to address this fragmented landscape and improve efficiency as a means to strengthen health systems and progress towards universal health coverage (UHC).
The Cross Programmatic Efficiency Analysis (CPEA) diagnostic, developed by WHO, uses an applied health systems analysis approach to understand the areas of fragmentation across specific aspects of health programs, and identify mechanisms and processes to address this fragmentation through targeted reform and action. In its application in 14 countries to date across Africa and Asia, the CPEA has led to important processes — bringing together, building consensus among, and aligning diverse sets of stakeholders from across health sectors.
On July 11th 2023, the World Health Organization (WHO), Results for Development (R4D) and the Strategic Purchasing Africa Resource Centre (SPARC) hosted a session at the 15th international Health Economics Congress (iHEA) where researchers from Cameroon, Mozambique and Nigeria presented preliminary findings from the use of the CPEA diagnostic in their countries. This blog shares the key messages from the session and insights for other countries looking to understand their health system performance challenges related to fragmentation.
Improvement of health system performance is a collective responsibility
In Cameroon, Mozambique and Nigeria, as in many other low and low-middle income countries, health programs for the prevention and treatment of HIV and AIDS, Malaria, Tuberculosis, immunization, family planning, Neglected Tropical Diseases, among others, are heavily donor funded. This, in part, has crowded out public resources for these priority areas.
However, over-reliance on donor resources is not the only challenge. The CPEA diagnostic revealed that donor funding has ripple effects throughout the system, including how providers receive and allocate funds; how commodity stockouts and wastage are managed; how human resources are distributed and recruited; and how plans and budgets are established.
The three countries all stressed that addressing these structural issues is just as important as adding resources to support the delivery of priority interventions and services. But this requires coordination across the Ministry of Health with active involvement of health program leaders, donors, local government, public and private sector providers.
Politics matter
Many of these health programs are led by political constituencies that have power, resources and influence. Whereas coordination of the sector is usually vested in the Ministry of Health, in the three countries, there are separate institutions (Cameroon and Nigeria) or departments (Mozambique) that receive donor resources directly to manage these related activities, functions and interventions. De-fragmentation to improve efficiency will inherently shift roles and resources to better harmonize and integrate delivery of these priority interventions.
Recognizing these political dynamics ex-ante is essential to taking action. First, mapping and understanding the various stakeholders and their interests can help to develop strategies to mitigate potential challenges. For example, in Nigeria, federal agencies are responsible for coordination, planning and budgeting of donor resources of health programs. The 38 states have little autonomy and oversight of these programs yet are held accountable for their results despite low local-level ownership. For this reason, in Nigeria, engagement of both the federal- and state-level actors is critical to make further improvements in the delivery of these priority interventions to harmonize functions between the levels, and improve coordination and delivery of these services.
Identify entry points to address inefficiencies and bottlenecks
In Uganda, the CPEA process was used to introduce and familiarize stakeholders with the issue of fragmentation and its impact on health system performance. This is particularly relevant as Uganda prepares for transition from low-income to lower-middle income status, when donor funding is likely to decrease. Lessons from neighbors — including Kenya and Tanzania, already on this journey — have been used as Uganda identified entry points for engagement. By inserting the findings from the CPEA into national health financing discussions, the issue of fragmentation and the involvement of key health program stakeholders are brought into a more coordinated process.
For Cameroon, the impetus to harmonize and institutionalize the performance-based financing program, as well as the country’s voucher scheme for maternal health services has motivated the CPEA diagnostic. The intended findings will inform stronger government stewardship and management of both programs, as well as others within the system. This process is part of overall efforts to improve needs-based budgeting, health facility budget management, and more flexible management and allocation of funds at facility level.
In Mozambique, the CPEA diagnostic is complementary to other health system efficiency studies, such as the Public Expenditure Review. This is part of the health financing strategy in Mozambique that aims to maximize outcomes under a resource-constraint context. The CPEA is providing a deep-dive analysis to identify opportunities for service integration and funding alignment for a more sustainable and responsive national health system.
A health system is complex and multiple interlinked factors contribute to underperformance
A health system is complex with a dynamic interplay between diverse inputs required in the delivery of health services — for example, well-trained health workers, multiple types of medicines and commodities, expensive infrastructure and equipment, accurate and timely data to support decision-making. In addition to these complex inputs, there are broader social determinants of health that impact the structure and functioning of the health system — gender dynamics, education, water and sanitation, environmental factors including climate change. As COVID taught us, the emergence of new diseases is unpredictable. Yet, health systems must be agile enough to address new threats while responding to existing health challenges within a complex ecosystem with diverse stakeholders.
Current health programs were set up to address priority interventions. And these programs did result in some initial gains, but they also led to silos and health systems that are unresponsive to new and emerging health threats. Additionally, these programs are now experiencing a ceiling on their performance, which can only be overcome if health system underperformance is addressed more holistically and efficiently. For example, reaching the target of 90% vaccination rates will require better integration of vaccination services with antenatal and postnatal care. This integrated approach can raise awareness of mothers to the benefits of vaccinating children and improve access by reducing social and financial barriers to seeking care. But it can only be achieved when the whole health system works together, while complementing the efforts of other sectors to address social determinants of health access.
As demonstrated in the examples of Cameroon, Mozambique and Nigeria, the CPEA diagnostic has highlighted key areas of fragmentation that impact efficiency and overall health system performance, including: (1) uncoordinated, rigid and programmatically oriented health financing arrangements that hamper allocation of resources, (2) weakened stewardship capacity of the Ministry of Health and a complex political economy due to the myriad of stakeholders and resources involved and (3) duplicative and disconnected system organization and service delivery.
The challenges may not be new, but the value CPEA brings is the process of engaging a broad range of stakeholders and drawing them to the table, to identify and prioritize the opportunities to address these challenges. In Cameroon, Mozambique and Nigeria, they are on the path to co-creating solutions to reduce fragmentation, improve their health system performance and make further progress towards UHC.
