ABSTRACT
BACKGROUND: In May 2015 the Malawian Ministry of Health (MOH) contacted the German Development Cooperation to seek technical assistance from the P4H Network for Social Health Protection for an "Assessment of the appropriateness and feasibility of National Health Insurance in Malawi" against two alternative options: continuing with a tax (and donor)-funded National Health Service, and introducing a purchaser-provider split without a revenue collection function. METHODS: A health financing benchmarking matrix was agreed with MOH, with six domains corresponding to six objectives: revenue mobilisation, technical efficiency, equity, financial risk protection, policy coordination, and health outcomes. The assessment comprised key informant interviews with Malawian stakeholders, a review of the relevant literature and datasets, rapid assessments of the Malawi Revenue Authority (MRA) and the Unified Beneficiary Registry (UBR), and projections of the National Health Insurance Scheme's (NHIS) revenue collection costs and benefits. RESULTS: A key finding was that introducing NHIS in Malawi would increase revenues for health, but these would come predominantly from the formal sector and would be unlikely to cover the health sector funding gap. The performance of existing poverty identification and targeting mechanisms was not commensurate with the requirements of a NHIS. Incentives to enrol in NHI are insufficient to reach scale unless service fees be introduced, which would negatively affect equity and financial risk protection. The assessment identified the Purchaser Scenario as the most favourable reform model. CONCLUSIONS: As ever more countries look towards implementing National Health Insurance, the proposed assessment framework can provide an orientation for evidence-based policy making in the area of health financing.
ABSTRACT
BACKGROUND: The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2012-2015. It aimed to answer evaluative questions raised by policymakers in Ministries of Health, rapidly and with limited resources. The aim of our evaluation was to assess whether the 3DE model was successful in supporting and increasing evidence-based policymaking, building capacity and changing behaviour of Ministry staff. METHODS: Using mixed methods, we compared the ex-ante theory of change with what had happened in practice, why and with what results (intended and unintended), including a qualitative assessment of 3DE's contribution. Data sources included a structured quality assessment of the five impact evaluations produced, 46 key informant interviews at national and international levels, structured extraction from 170 programme documents, a wider literature review of relevant topics, and a political economy analysis conducted in Zambia. RESULTS: We found that 3DE had a very limited contribution to changing evidence-based policymaking, capacity and behaviour in both countries as a result of having a number of aspirations not all compatible with one another. Co-developing evaluation questions was more time-consuming than anticipated, Ministry evidence needs did not fit neatly into questions suitable for impact evaluations and constricted timeframes for undertaking trials did not necessarily produce the most effective results and value for money. The evaluation recommended a focusing of objectives and a more strategic approach to strengthening evaluative demand and capacity. CONCLUSIONS: Lessons emerge that are likely to apply in other low- and middle-income settings, such as the importance of supporting evaluative thinking and capacity within wider institutions, of understanding the political economy of evidence use and its uptake, and of allowing for some flexibility in terms of programme targets. Fixating on one type of evidence is unhelpful in the context of institutions like ministries of health, which require a wide range of evidence to plan and deliver programmes. In addition, having success tied to indicators, such as number of 'policy decisions made', provides potentially perverse incentives and neglects arguably more important aspects such as incremental programmatic adjustments and improved implementation.
