How can health financing models (the way funds are raised and used to organise health systems and cover health needs) be adapted to fragile and conflict-affected settings?

Our world is being negatively impacted in many different ways right now. Weak governance, fragility and shocks - whether linked to conflict, political and social shifts, health emergencies and epidemics or climate change - are on the increase globally.

The World Bank estimates that two billion people now live in situations affected by fragility and conflict and more will be affected in the near future. At the same time, extreme poverty and maternal and under-5 deaths are more prevalent in the areas affected by these situations - more than one third of maternal deaths occur in fragile settings, and half of the children who die before age five live in fragile settings. Progress towards universal health coverage and meeting the Sustainable Development Goals (SDGs) defined by the United Nations, in these areas is particularly challenging.

While improving health financing systems is critical to enable countries to raise more resources for health and make good choices about how to use them, there is limited evidence and little guidance which is specific to fragile settings, e.g. there is little in the way of specialist guidance to assist a country like Sierra Leone to rebuild their health systems to meet the population health needs after a decade of civil war and the Ebola epidemic. However, these settings face specific challenges not only in relation to their health needs, but also due to lack of funding, dependence on external aid for prolonged periods and the weak capacity of local institutions and systems through which funds could be channelled.

The Institute of Global Health and Development at Queen Margaret University has worked extensively on the multidisciplinary evaluation of innovative financing models, such as Performance Based Financing (PBF), in fragile settings. PBF involves providing a payment to front-line providers (e.g., health centres) based on the number of services (from a well-specified list) that they provide to the population, instead of paying them a fixed amount – or nothing at all - and letting patients pay for much of the costs of services out of their own pocket. PBF has been increasingly implemented across many low income settings.

It is now one of the main channels for financing front-line providers, often supported by international donors, such as the World Bank providing aid to those countries. However, up until the 2010s, there remained a dearth of evidence on PBF’s impact on health service delivery or population health outcomes.

In 2012, Professor Sophie Witter and colleagues from Queen Margaret University produced the first systematic review of PBF in low and middle-income countries, which was then updated in 2021.This paper marked a turning-point in the understanding and practice of PBF, highlighting the importance of examining PBF as a health system intervention – which means, in connection with multiple aspects of the health system, also exploring its potential unintended and broader effects. This work prompted further research from the global research community, and the IGHD research team built a large portfolio of research around that, including theoretical work and empirical studies in DR Congo, Central African Republic, Nigeria, Uganda, Georgia and Zimbabwe.

Based on this work detailed above, the IGHD researchers at Queen Margaret University have become a source of expertise for research on innovative health financing in fragile settings. The research group as provided expert support to with international organisations, such as the World Bank, World Health Organisation (WHO), Global Fund to fight HIV/AIDS, TB and Malaria (GFATM) and the UK’s Department for International Development (DFID, now Foreign, Commonwealth and Development Office) to assess the evidence and develop guidance, and have provided technical assistance and support to Ministries of Health in fragile countries.

Queen Margaret University researchers provided expertise in innovative health financing solutions for fragile settings to assist international organisations, such as the World Health Organisation (WHO), as well as ministries of health in fragile countries. This expert support is assisting countries in their recovery from conflict, poverty, climate change, weak governance, epidemics, etc.

1. The work of IGHD has driven the debate in the community of researchers and practitioners (for example, NGOs and humanitarian agencies) working on health financing and PBF. IGHD’s research has improved the understanding of PBF, shaped the debate on advantages and risks of PBF and established Witter and team as leading experts and advisers on innovative health financing and PBF.

2. Research findings have influenced policies and practices of international organisations, such as the World Bank, WHO, GFATM and DFID. The World Health Organisation, the global health normative leader, has developed guidelines on health financing in fragile settings in collaboration with the IGHD team. These documents are part of the WHO e-Learning Course on Health Financing Policy, which has trained teams from more than 40 countries. The World Bank is one of the largest funders of PBF and has spent more than $380 million on PBF schemes in 29 countries. It has developed a portfolio of impact evaluations in response to critiques about the evidence base for PBF. More recent approaches to health financing through the World Bank’s Global Financing Facility (investing $602 million in 26 countries) have recognized IGHD’s contribution, opting to not make funding dependent on adoption of PBF. The IGHD group has also supported the GFATM’s strategy and guidelines to work in Complex Operating Environment (COE) and provided a tailored review for the Global Fund on how to support PBF and direct facility financing across its portfolio.

3. In the UK, IGHD’s research on health financing and PBF has been incorporated into guidance for the Department for International Development (DFID – now Foreign, Commonwealth and Development Office/FCDO), one of the main bilateral funders of PBF historically.

4. IGHD’s research on health financing is designed and carried out in ways that ensure relevance for national policy-makers, in low-income fragile settings. The team has provided direct support and technical assistance to the Ministry of Health in Zimbabwe, Sierra Leone, Georgia and now in Afghanistan, and has directly shaped national policy to ensure more effective health financing.

5. By shaping policies and practices, IGHD’s work on health financing has had significant impact on financial protection and population health, particularly in fragile and conflict-affected states, protecting households from poor quality health care and undue out of pocket payments.

Academics involved in leading/contributing to this research:

Dr Sophie Witter, Professor

Dr Maria Bertone, Lecturer

Dr Karin Diaconu, Research Fellow

Research and Knowledge Exchange Development Unit

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Research and Knowledge Exchange Development Unit

Kim Stuart Head of Research and Knowledge Exchange Development Unit 0131 474 0000
RKE - Vivian Rutherford Research and Knowledge Exchange Officer 0131 474 0000