TAF- 15 NHA: Mid
Health Financing Expert -
E4H Programme Federal

 TORs: National Health Financing Expert

FEDERAL TA: Development of a Policy Brief on All rounds of NHA and RECENT Health Budgets

Programme

Evidence for Health (E4H) is a Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness and saving lives. E4H provides technical assistance (TA) to the Federal, Khyber Pakhtunkhwa (KP), and Punjab governments, and is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H delivers TA across three outputs:

Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.

Output 2: Strengthened evidence-based decision-making to drive health sector performance and accountability.

Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

Background and Problem Statement

The National Health Vision (2016-25) - Pillar II (Health Financing) emphasises strengthening health financing to achieve universal health coverage (UHC) and improve overall health outcomes. It aims to increase federal and provincial health spending to 3 percent of the Gross Domestic Product (GDP), enhancing health service delivery and coverage. The Vision includes health financing reforms such as social health protection initiatives to reduce financial barriers for poor families, mitigating the burden of out-of-pocket expenditures.

• The NHV targets are of utmost importance, as they represent our collective goal for the future of health financing. However, the Government Health Expenditure (GGHE) percentage of GDP remains below these targets, indicating a persistent gap between our aspirations and actual outcomes. While there has been a modest increase in GGHE as a percentage of GDP and General Government Expenditure (GGE), these increases are insufficient to meet the NHV 2016-25 targets.
• Health Financing faced significant challenges recently due to economic disruptions from post-pandemic fiscal issues, leading to financial strain and reduced economic activity. The decline in tax and non-tax revenues hindered the goal of increasing health spending to 3 percent of GDP as per NHV 2016-25.
• Despite adopting Budget Strategy Papers (BSP) and Medium-Term Budgetary Frameworks (MTBF), their impact on actual budgets remains weak. The Project to Improve Financial Reporting and Auditing (PIFRA) system's coding structure also fails to support resource allocation according to UHC targets. Health expenditure initially increased as a share of the total government budget, with Sindh rising from 10.8 percent in 2016 to 19.2 percent in 2020.
• The proposed solutions have the potential to improve the current situation significantly. Budgets heavily weighted towards recurrent expenditures, especially salaries, can be restructured to allow for more funds for non-salary and development purposes. This could help address health resource discrepancies amid competing fiscal demands and a constrained economic environment exacerbated by post-pandemic recovery challenges, rising global commodity prices, and domestic fiscal pressures.
• The latest National Health Accounts (NHAs) show that government health expenditure (GHE) as a percentage of GDP remains below targets, with out-of-pocket (OOP) expenditures making up 47 percent of current health expenditures, though reduced from 53 percent in the previous round. External aid as a percentage of GHE fluctuates, reflecting variable reliance on external funding. The average health allocation of 9 percent of the national budget is insufficient for UHC goals, with budgets often not based on health needs, inadequate, or delayed, affecting service quality.
• The Sehat Sahulat Programme (SSP), a social health insurance initiative started in 2015, offers inpatient healthcare funded by federal and provincial budgets and is expanding. Future comprehensive insurance across Pakistan could advance UHC but faces challenges like the lack of an outpatient package and financial viability concerns.
• Misalignment of the current Chart of Accounts with health services prevents detailed tracking of healthcare expenditures, and inefficiencies in managing non-wage expenses persist due to excessive internal controls without thresholds.
• The M/o NHSRC has proposed this TA to synthesise NHAs data series since 2005-06 (and including the latest 2021-22 round) and brief health budget analysis to produce a policy brief to be used for sensitising policymakers and introducing health financing reforms in the province.
• The NHA and budget analysis policy brief can be used for multiple purposes, including (i) advocacy for resource allocation, (ii) evidence-based decision-making, (iii) monitoring and evaluation, (iv) policy planning and reforms, and (v) international comparison and benchmarking. The evidence will also be useful for forth-coming sectoral and sub-sectoral policies/strategies in health.  
• The use of NHA data and budget analysis has been restricted, primarily due to their complexity, which poses challenges for many policymakers and planners to comprehend in their current structure. Furthermore, the limited information about the existence of such data has also contributed to its underuse.
• With increasing investments in Pakistan's healthcare sector, particularly through initiatives like the SSP, the contracting of health facilities, giving autonomy to tertiary hospitals, and the implementation of UHC benefit packages/ essential package of health services (EPHS), there is a growing imperative to present this information in a more understandable format for policymakers and decision-makers.

Objectives

This TA aims to develop a comprehensive policy brief on the NHA and recent Budget Analysis using the evidence from all the NHA rounds and recent budget data.

Scope of Work and Methodology

As a part of this TA assignment, the team will cover the following scope of work:

1. Collaborate with the M/o NHSRC to identify key stakeholders who will be the primary users of the policy brief. This step is crucial for ensuring that the brief is tailored to the needs and interests of its intended audience. The M/o NHSRC will facilitate the acquisition of this data from the Pakistan Bureau of Statistics (PBS) and the Planning Commission. This data will form the backbone of the analysis in the policy brief.
2. Conduct a literature review to gather comprehensive insights and evidence. This step ensures the policy brief is grounded in existing research and evidence, providing a solid foundation for its recommendations.
3. Tailor health financing flows. This involves detailing the allocation and distribution of financial resources within the public healthcare system, providing a clear picture of current financial flows and potential areas for improvement.
4. Develop an outline for the policy brief and seek feedback from relevant stakeholders. A similar exercise was also used in the KP province. The outline should detail the key areas of analysis and structure the document coherently and logically.
5. It will involve examining, analysing, and synthesising data from all rounds of the NHA and recent budget data to inform and support the key insights and recommendations outlined in the policy brief, including information related to health equity.
6. Develop the first draft of the policy brief, incorporating schematic diagrams to visually represent key findings and analysis. These visuals should help convey complex information in an accessible and engaging manner.
7. Finalise the policy brief by incorporating stakeholder feedback and addressing comments or concerns. Ensure the document is agreed upon by the M/o NHSRC and ready for dissemination to the ministry personnel or presentation, effectively communicating its findings and recommendations to its intended audience.

Timeline and LOE

The level of effort for the role is 40 working days, from Aug – Oct 2024.

Requirement

Technical Expertise

1. Postgraduate degree in public health and health financing.
2. Minimum of 10-15 years' experience.
3. Strong understanding and experience of using data analysis tools and software to analyse and interpret complex healthcare financial data.
4. Experience in evaluating the efficiency and effectiveness of healthcare programs using data-driven approaches is also important.

 Competencies

1. Analysing and using information
2. Decision making; Influencing

Deliverables

1. Draft policy brief
2. Final Policy brief and presentation after incorporating comments and suggestions