Fragility and conflict
Extreme poverty, premature mortality, and ill-health are increasingly concentrated in settings characterized by fragility and conflict (FCAS), often within otherwise stable countries. Fragility is an umbrella term, covering very different settings, fragile for different reasons. However, each is characterized by deficits in key government capacities, with clear implications for health financing policy.
The increasing fragility experienced globally presents a serious challenge for progress towards universal health coverage. To deliver on commitments under the Sustainable Development Goals and in the spirit of leaving no one behind, WHO offers a systematic approach to health financing policy in FCAS based on its health financing framework and guiding principles.
WHO’s general guidance on health financing policy in support of UHC
WHO’s work on health financing builds on the World Health Report 2000, which focuses on the four key functions of a health system, one of which is health financing. The health financing function is further unpacked into three sub-functions, namely revenue raising, pooling of funds, and purchasing of services, as well as policy on the design of benefits.
WHO has well-developed guidance for each of these sub-functions, building on a set of guiding principles which draw on both normative thinking and empirical evidence. The guiding principles focus heavily on the important role of government, particularly in terms of financing, to make progress towards UHC. Recommendations include taking measures to reduce fragmentation in the pooling of revenues, and to use these revenues to purchase services in a way which steers the health system in a more equitable and efficient direction. The role of public institutions in facilitating health financing, and in providing an appropriate and coherent incentive and regulatory environment across the health system is also central to UHC progress, a role which is often severely weakened in FCAS.
Key points about health financing policy in FCAS
The extent of fragility and conflict can vary substantially within a country, and health financing solutions need to adapt to reflect this. As domestic public revenues fall, the capacity and in some cases willingness, of government to deliver essential services and ensure financial protection reduces. As a result, external funding for both humanitarian and development programmes plays a critical role in maintaining the public nature of funding for the health system, and in safeguarding the provision of essential personal health services, as well as population level interventions.
Humanitarian funding can learn from development funding efforts to improve pooling and make purchasing more strategic, for example through contracting service provision. Increased dependence on external funding brings with it influence over plans, policies and implementation capacity, which can be either supportive or undermining of local leadership, systems, and capacity. Ensuring coordinated and coherent interventions across humanitarian actors, as well as between humanitarian and development operations, is critical both for short term effectiveness and for the development of a resilient health system in the longer term.
Financing disease surveillance, information systems, enforcement of health protection laws and regulations, planning and management of national strategies for health security, and other common goods for health is a priority in FCAS given the increased risks to health security. Where feasible, supporting core systems such as those required to pay salaries should take precedence over more complex payment methods. While cash and voucher assistance (CVA) modalities can improve access to and the use of health services in humanitarian settings, supply-side support for service delivery is also required.
Where possible crisis-affected vulnerable population groups, such as refugees or the internally-displaced, should be incorporated into existing national health coverage schemes.