Cairo Global Health History Draft v1 May 1.pptx

political economy

1. Global Health Histories Seminar 126: Political Economy (Re)Understanding health system financing reforms in Low-and-Middle-Income Countries The crossroads of politics, history and economics Sumit Mazumdar, PhD Research Fellow (Global Health Economics) Centre for Health Economics, University of York York, United Kingdom

2. Contents The terrain of health system financing reforms towards UHC goals Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

3. Why UHC? Best means to achieve health system goals – better health, fairness in financing and responsiveness – ingredients for SDGs (Goal 3, Target 3.8) For people-centred health systems – ensuring none, with any health needs is left out Welfarism, public accountability and State legitimacy ALL PEOPLE can obtain the quality services they need without facing financial hardships (GMR, 2017)

4. UHC – A misinterpreted journey? UHC is more about sustained progress towards ensuring its goals which also keeps changing – the UHC horizon Is as much about national health insurance as about ‘general’ tax-financed health services – number of UHC success stories are tax-financed, predominantly public sector provided services The ‘path to UHC’ ( Kutzin , 2012) Predominance of compulsory public funding, not voluntary insurance Larger pools, redistribution across diverse populations Ensuring efficiency and accountability through ‘strategic’ purchasing Not about big banner schemes, but fundamental changes in health system

5. Different paths, Common roads Common patterns across countries in different stages of implementing UHC-oriented health system financing Involves three core financing functions – Raising the required revenue ; Pooling risks across the population through prepayment and Purchasing the required health services through suitable provider (and other health inputs) payment mechanisms Most countries adopting general govt revenues/taxes, payroll contribution (revenue generation), multiple risk-pooling (formal sector workers, informal/poor), and mixed models of service delivery (but with clear public roles in purchasing) Always rooted in political leadership and decision-making, bureaucratic involvement and functioning of institutions and interest-groups

6. Contents The terrain of health system financing reforms towards UHC goals Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

7. Policy processes in health system reform 4 is the favourite! The four ‘political’ stages of policy reforms (Reich,1995; Fox & Reich XXXX) Agenda-setting, Technical design, Adoption & Implementation The four drivers on influence on health policy outcomes: Interests, Institutions, Ideas and Ideologies The four Is

8. The writ of the State Historical evolution of welfarism & accountability (or the lack of it..)

9. How and why do institutions differ? Insights from New Institutional Economics

10. Methods and Materials for Political Economy Analysis of Health Financing Reforms Process-tracing approaches for policy reforms in each of the three health financing functions - how revenues are raised, how the risk pool is formed and who gets in or not, how services are purchased and from whom? Any single theoretical framework unlikely to explain actions across all the domains, e.g. political frameworks for inclusion in insurance pools and taxation, institutional economics to explain contracting Mixed-methods, Mixed-sources : Combine cross-national data (Policy4, WGI, WHO HE database) with qualitative approaches; derive comparable metrics of governance and institutional performance, political inclusiveness etc

11. Key Message 1 Understanding the introduction and implementation ( or not doing so ) of UHC financing reforms is not just about identifying whether the right ideas and solutions (‘models’) are available, but tracing the dynamic historical evolution of the political system and other groups and institutions as the critical pivots of reform

12. Contents The terrain of health system financing reforms towards UHC goals Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

13. What is political about policy reform?

14. Political models of policy reform

15. Policy cycles in health system reform

16. The 4Is of political parameters

17. The framework of political settlements

18. Applying political settlement theory for contemporary UHC reforms

19. Key Message 2 AAAAA

20. Contents The terrain of health system financing reforms towards UHC goals Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

21. Weak States or Reluctant States? The Historical Roots of Welfarism

22. Why can’t we avail of ‘Windows of Opportunity’? Triggers matter, but contexts even more

23. ‘Sticky’ Policies : The quicksands of Path Dependency

24. Reconciling diverse functioning of similar institutions in policy-making The promise of New Institutional Economics

25. Key Message 3 BBBB

26. Contents The terrain of health system financing reforms towards UHC goals The Toolbox: Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

27. New imperatives for public & private roles in health financing & policy

28. Beyond the Obvious : Ignored questions on public purchasing of health services from the private sector

29. Framing strategic purchasing from the perspective of NIE

30. Key Message 4 AAAAA

31. Contents The terrain of health system financing reforms towards UHC goals The Toolbox: Multidisciplinary frameworks and methodologies to understand health policy reforms Mapping key political drivers of health financing programmes Evolutionary histories of institutions and political systems as drivers of policy reform processes Understanding the face-off between the State and the Market in health policy reform An agenda of research on the political economy of UHC in LMICs

32. Dissecting UHC policy landscapes through multidisciplinary lenses: The Pursuit of Questions

33. Acknowledgements