Summary of the impact

Public financing of health services in low income countries was challenged by the World Bank's Agenda for Reform in 1987, which advocated increased roles for private sector, private insurance and user fees. This was followed by a wave of reforms implementing this approach. McPake has been involved in researching the implications of this shift since this period and has published a series of influential articles that have had a demonstrable impact on this debate. Removal of user fees for all, or selected, services or for selected population groups has occurred in many countries, including 28 of 50 countries with the highest maternal and child health mortality included in a recent survey (http://bit.ly/17FUiDM).
Witter is the lead researcher who has examined country level experiences of removing fees and it is demonstrable that her work has been applied in specific countries to shape the details of policy and has also had a major influence on the global debate.

Underpinning research

McPake's early work arose from the Health Economics and Financing Programme, a DFID- funded research programme held by the London School of Hygiene and Tropical Medicine. This included desk-based literature review research which queried the theoretical and empirical basis of the World Bank's argument (McPake, 1993) and a co-funded (by DFID, SIDA, Norwegian government, DANIDA, and UNICEF) analysis of the Bamako Initiative (an initiative with decentralised user charges at its core), which conducted mixed method case studies in four countries. This demonstrated the complexity of the realities of health financing impacts. This work was followed by an EU-funded research project (1994-1997) in Uganda, which explored these complexities further and was the first research focusing on the supply side response to financing policy change, issues at the core of the current discussion (McPake et al., 1999).

Witter's work before joining QMU, as a principal health economist on the IMMPACT programme held by Aberdeen University, has focused on the development of multidisciplinary tools to assess health-financing impacts, understanding the preconditions for policies addressing the effectiveness of financial barriers and developing a better understanding of the relationship of financial and other barriers to health care access, such as transport and cultural factors. Among the important findings from this work are that involving and incentivising staff is a critical component in the implementation of health-financing policy and this insight prompted further work, including a systematic review for the Cochrane collaboration (Witter et al., 2012).

McPake's more recent research undertaken at QMU has included desk-based research relating analysis of cost and health worker time allocation to the financial implications of user fee policy change. This was part-funded by Save the Children Fund. A tool to help countries that want to remove user charges to do so was developed (McPake et al., 2011, http://bit.ly/H8HbWL). McPake, Witter and Fustukian (Senior Lecturer, IIHD) completed the study, `Equitable health financing and human resources for health' (2011), which undertook five country case studies of the inter-relationships between health financing reform and the health workforce, funded by DFID (McPake et al., 2013). ReBuild Consortium work (2012-2014: McPake, Witter and Fustukian) is further considering the issues of financing policy reform in post-conflict fragile states, addressing the implications of financing policy change on household health expenditure and evaluating policies that aim to support the supply side under `free' health care (Witter, 2012).

Key staff moved to QMU within the period discussed and impacts from their continuous research outputs over the period are included in this account. McPake joined QMU in 2005; Witter joined QMU in 2011. The programme of research reported spans their work in multiple institutions but is now embedded and brought together in QMU. Fustukian joined QMU in 2001.

References to the research

Evidence of the quality of the research
This research has been published in leading journals in the international health policy area, Social Science and Medicine and Health Policy and Planning. It includes a Cochrane Review, which is considered by some to represent the gold standard for literature assessment, and, while we take a broader epistemological view, we do consider this implies that the standards required are challenging and rigorous.

Those articles that have had sufficient time in the public domain have been cited extensively in the academic literature as well as the policy literature; McPake(1993) has been cited 73 times, McPake et al. (1999), 84 times. The research has been funded through competitive sources including DFID and the EU.

Details of the impact

Influence on the global policy shift in charging for essential health care
Multilateral and bilateral agencies have had a significant influence on this area of policy in most low income countries. Major influencing bodies, such as the World Bank, UNICEF and WHO, now all emphasise the need to make essential services free at the point of use, reflected in the Universal Health Coverage movement and marked by the 2010 World Health Report. This change has influenced national policies in a range of countries. At the country level, a recent mapping study found that more than half of the high-mortality countries surveyed (28 out of 50) had, in the last few years, introduced reforms to their user fee regimes (http://bit.ly/17FUiDM). Our citation (see below) in major policy reports of these agencies implies use of the research in the relevant policy processes and continuous citation over a 20 year period demonstrates sustained inputs.

Our work can also be shown to have been used in the development of specific bilateral agencies' policy responses, including those of both DFID and DANIDA which have both significantly supported development of alternatives to user fees. For example, McPake's work was the primary basis on which Save the Children lobbied DFID to the effect that "Save the Children UK believes that ensuring equitable financing of healthcare is the single biggest contribution that DFID could make (to improving reproductive, maternal and newborn health outcomes)".

McPake and Witter's work has supported Save the Children in its advocacy and policy advisory work more generally. The `Freeing-Up Health Care' tool (http://bit.ly/H8HbWL) developed by McPake and others, was commissioned for this purpose and Witter was also commissioned to review the whole debate in 2005. We have also undertaken specific pieces of research for Save the Children, reviewing health insurance proposals in Sierra Leone and documenting financial barriers to access in Tanzania.

Policy change and effective implementation in country
We have contributed directly to policy and policy implementation detail in specific countries. Witter has been invited to be a technical expert supporting countries in moving towards universal coverage. She has provided advice to Sudan, Nepal, Ghana, Liberia and Vietnam.

In Ghana, Witter's evaluation of the maternal fee exemption policy raised serious concerns about the funding, implementation and sustainability of the policy. These contributed to revision of the policy, with financial protection of pregnant women ultimately being transferred to the National Health Insurance Scheme (NHIS) in 2008. In the first year of implementation alone, 433,000 additional women had access to health care. Advisory work by Witter, including heavy involvement in annual health sector reviews in 2006, 2007 and 2009, has also contributed to the development of the NHIS.

Since then the tools developed in Ghana have been used in adapted form in other countries introducing similar policies — for example, in Senegal and Mali. In Nepal, the tools were adapted to evaluate and propose refinements to the Safe Delivery Incentive Scheme, which has raised utilisation of skilled delivery (http://1.usa.gov/GWCyi2) and contributed to the decline in maternal mortality (http://bit.ly/1an6Q4D). In Sudan, these tools were used to review the policy of free caesareans and care of under-5s. This was then reformed and re-launched by the Federal Ministry of Health, with advice from Witter. The lessons learned on policy design and implementation are now guiding her advice to Sierra Leone, Mali, Benin, Burkina Faso and Morocco.

Impacts for ultimate beneficiaries
The ultimate beneficiaries of these policy changes are those whose access to care is made easier by the removal of financial barriers or who avoid financially-catastrophic payments. Pregnant women and young children have often been targeted for free care and have benefited disproportionately. According to the research conducted by McPake and Witter among others, these groups will benefit in terms of reduced mortality and morbidity, reduced impoverishment related to out-of-pocket payments and mitigation of the diverse negative effects of coping strategies (debts, sale of assets, increased work for household members). Further work is needed to quantify these impacts.

In addition, there are knock-on benefits for national economies. Globally, $15 billion was estimated in 2001 to be lost every year due to reduced productivity related to the death of mothers and neonates (according to USAID: http://1.usa.gov/1c6YgxN).

Sources to corroborate the impact

Continuous citation in UN Reports and publications from 1993 onwards, indicating contribution to policy influencing debate:
Citation in World Bank reports
World Development Report, 1993 pp181, 189; Better Health in Africa, 1993, p207; World Development Report 2000/2001 (p223 Citation is Asiimwe 1997; full reference is Asiimwe, McPake et al., 1997); World Development Report 2012, p321.
Citation in World Health Reports, 2005, p38; 2006, p16; 2008, p37; 2010, 10+ citations; Countdown to 2015 report, 2008 (Tracking progress in maternal, newborn and child survival).
Citation in UNFPA Reports: State of the World's Midwifery (UNFPA, 2011) p159; UN Millennium Project: Who's got the power (2005), p98.
Citation in UNICEF Reports: Removing user fees in the health sector in low-income countries: a multi-country review, 2009, made `extensive use' of Witter's work (see acknowledgements); Removing user fees in the health sector in low income countries, policy guidance note for programme managers, ITM report for UNICEF, 2009.
Citation in (ILO) World Labour Report, 2000, p91.
Citation in the Commission on Macroeconomics and Health, 2002, Working Group 5, p121.
We are also extensively cited in analytic documents and background papers that have informed the policy direction taken by these reports and in practice guidance issued by UN agencies.

Direct influence over bilaterals, DFID and DANIDA
DFID: Prominently cited in two Save the Children Fund's submissions to DFID, 2008 as providing the evidence that DFID should support equitable financing of health care http://bit.ly/1gEpHyl; http://bit.ly/19DI2qe
Cited in oral and written evidence to the International Development Committee on (1) HIV/AIDS — DFID's new strategy; 12^th report 2007/8, p101 http://bit.ly/GPtXNA
(2) DFID's programme in Nigeria, 2009 8^th report 2008/9 http://bit.ly/GWAsyz
DANIDA: Cited in Draft Proposal for a new DANIDA health policy, 2001 http://bit.ly/16ZCl9H
Cited in Schleimann, F., Enemark, U. and Byskov, J. (2003) Development assistance to the health sector: a Danish perspective (no longer available online but hard copy of relevant text available from QMU; Schleimann was Danish Ministry of Foreign Affairs Chief Technical Advisor on Health) Cited in Evaluation of Danish Bilateral Assistance to Health 1988-1997 http://bit.ly/164E0Kw

Influence in Specific Countries
(a) Direct input into health policies and plans:
Witter, S. and Fox, S. (2011) National health policy and strategic plan for Liberia, 2011-20, Report for Government of Liberia (not online; can be supplied if requested).
Thompson, R, Witter, S. and Nguyen, N (2011) Strategic options for financing health system modernization and development: what can Vietnam learn from international experiences? Report for Development Strategy Institute, Ministry of Planning and Investment, Hanoi. http://bit.ly/GPv28i
Witter, S. et al. (2009) Pulling together, achieving more: independent health sector review for 2008, Accra, Ministry of Health http://bit.ly/19LfzRh
Witter, S. (2007) Financing the health sector, 2007-11. Technical paper for Ghana Five Year Programme of Work, 2007-11. Accra: Ministry of Health. (not online; can be supplied if requested).

(b) Articles written with policy makers:
Witter, S., Adjei, S., Armar-Klemesu, M. and Graham, W. (2009) Providing free maternal care: ten lessons from an evaluation of the national delivery exemption policy in Ghana, Global Health Action, Volume 2 http://bit.ly/GWB5s0 Adjei, was Acting Director General, Ghana Health Service.
Witter, S., Khalid, K., Abdel-Rahman, M., Hussein, R., Saed, M. (2012) Removal of user fees for caesareans and under-fives in northern Sudan: a review of policy implementation and effectiveness, International Journal of Health Planning an Management (all Sudanese authors are Ministry of Health officials).

Individual users/beneficiaries who could be contacted by the REF team to corroborate claims:
Former Chief Economist, World Bank; Senior Health Advisor DFID/WHO, Senior Health Policy and Research Advisor, Save the Children; Executive Director, National Health Insurance Fund, Sudan; Former Deputy Director, Ghana Health Services.

Testimonials held by the University
First Secretary, Royal Danish Embassy, Accra, testimonial to the quality of Witter's inputs to the Ghanaian health sector reviews listed above.