The Harvard Ministerial Leadership Program In association with Big Win Philanthropy and with the support of the Bill and Melinda Gates Foundation

Report compiled by Helene Perold and Dr. Reason Beremauro for Helene Perold & Associates

Report on effects of the Ministerial Leadership Program as reported by ten

Finance Ministers

September 2017

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Table of Contents Executive Summary ................................................................................................................... 2

1. Introduction ........................................................................................................................... 4

2. Evaluation Methodology ....................................................................................................... 5

3. Findings and Analysis of Ministers of Finance Interviews ..................................................... 8

i) The role of finance ministers in strengthening health systems .................................... 8

ii) Finance ministers’ changing perspectives of their roles ............................................. 10

iii) Leadership in relation to strengthening the health sector ......................................... 16

iv) Collaboration between health and finance ministers to strengthen health sector performance........................................................................................................................ 19

v) Budget efficiency and effectiveness ............................................................................ 23

vi) Challenges in implementing effective and efficient use of health budgets ................... 28

4. Concluding observations ....................................................................................................... 31

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“The Harvard Program helped me to see all the aspects of having a health system in which primary care is one of the first pillars. And that was that fact that you can have an impact on economic growth, on workforce productivity and also have a very good impact on the value chain on expenditure in the health sector.” Finance Minister 2

Executive Summary This report provides an analysis of the effects of the Harvard Ministerial Leadership

Program drawing from the perspectives of Ministers of Finance from selected

African countries who attended the Ministerial Leadership Forum for Finance

Ministers between the years 2014-2017.

The analysis presented in this report is drawn from interviews that were conducted

in June and July 2017 by the Principal Evaluator of the Harvard program, Ms. Helene

Perold. A total of ten interviews were conducted with current and former Ministers

of Finance from the following countries: Burkina Faso, Cabo Verde, Ethiopia, The

Gambia, Liberia, Mozambique, Sierra Leone, South Africa and Tanzania. In the

Gambia, both the former and incumbent Ministers of Finance were interviewed. The

evaluation findings provide a deeper and nuanced analysis drawn from the

participants’ specific contexts.

The overarching goal of the Harvard Ministerial Program is to stimulate

transformative vision, enhance leadership effectiveness and political acumen as well

as develop planning and implementation capacity among ministers. This report

specifically examines and highlights the ways in which these finance ministers’ goals

and their collaboration with Ministers of Health (MoH) translated into systems,

processes and outcomes for the health sector in their respective countries.

The evaluation findings indicate that one of the

fundamental principles ministers learnt from the

Harvard Ministerial Leadership Program was the

need to strengthen health systems in order to

ensure improved health and human development

outcomes. As a result of this understanding some

of the ministers prioritized funding primary health

care and embarked on initiatives to promote

universal access to health care in order to ensure

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that the health sector supported development and economic growth within their

countries both in the short and long term.

The Harvard Program changed ministers’ perceptions about their leadership roles

and strategic functions. The findings indicate that the ministers embraced greater

accountability responsibilities and in turn they held other ministers accountable for

budget allocations. Some of the ministers changed the way they led their ministries

and they implemented notable changes such as adopting results-based systems and

approaches in conducting government functions, duties and responsibilities.

In instances where both finance and health ministers participated in the Harvard

Program there was greater synergy and collaboration between them, and this

understanding produced better outcomes than in cases where only the finance

minister had attended the Program. The closer collaboration between the finance

and health ministers enabled the ministers to articulate and better support plans,

procedures and systems for their health sector priorities.

The findings show that these finance ministers sought to increase fiscal space, curb

wastage, cut costs, and generate revenue –

measures that collectively aimed to improve health

budget efficiency and effectiveness. In cases where

some of the finance ministers failed to achieve

their targets there were external factors that

hindered them such as emergencies, electoral processes and cabinet reassignments.

Among some of the notable systems, processes and outcomes introduced by the

ministers are the following: results- and performance-based systems of budgeting

and resource allocation; the creation of management teams within cabinet:;and

setting up new management systems with regular reporting and monitoring

mechanisms. Newly introduced processes included the prioritization of health

programs and activities; the allocation of resources to ministries that supported the

health sector; changing procurement systems; and upgrading health facilities in

“The Harvard Forum is an eye opener, in terms of how the budget can be executed, where resources are properly reallocated, and you can achieve maximum results.” Finance Minister 6

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order to curb the use of foreign currency in overseas medical institutions. Some of

the key outcomes include the audit of a health payroll; changes in procurement

systems; and the optimization of health expenditure. Collectively, these systems,

processes and outcomes contributed to the strengthening of the health care systems

in the different countries.

1. Introduction

This report provides an analysis of the effects of the Harvard Ministerial Leadership

Program drawing from the perspectives and experiences of ten Ministers of Finance

from selected African countries who attended the Ministerial Leadership Forum for

Finance Ministers between the years 2014-2017. The Harvard Program was initiated

in 2009 and is a joint initiative of the Harvard T.H. Chan School of Public Health,

Harvard Kennedy School and the Harvard Graduate School of Education. The

overarching goal of the Program is to stimulate transformative vision, enhance

leadership effectiveness and political acumen, and develop planning and execution

capacity among ministers from Africa, Southeast Asia, and Latin America. Ministers

are invited to participate in the Program based on the leadership capabilities they

demonstrate in their respective countries.

This report is part of a three-year independent evaluation of the Harvard Program

and it provides a detailed analysis of interviews conducted with the ten Ministers of

Finance (MoF) who attended the Ministerial Forum in different years. Specifically,

the analysis seeks to address the broad question of how the finance ministers’ goals

and their collaboration with Ministers of Health (MoH) translated into systems,

processes and outcomes for the health sector in their respective countries. The

analysis pays particular attention to how the ministers plans and initiatives aimed to

strengthen health systems to ensure improved health outcomes.

The section below outlines the evaluation methodology including the selection of

the Ministers who participated in the evaluation.

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2. Evaluation Methodology

The material presented here is drawn from interviews conducted during June and

July 2017 by the Principal Evaluator of the Harvard program, Ms. Helene Perold. A

total of ten interviews were conducted with current and former Ministers of Finance

from the following countries: Burkina Faso, Cabo Verde, Ethiopia, The Gambia,

Liberia, Mozambique, Sierra Leone, South Africa and Tanzania. In The Gambia, both

the former and incumbent Ministers of Finance were interviewed. All these ministers

attended the Harvard Ministerial Forum at some time between 2014 and 2017.

The participants were selected purposively taking into account factors such as the

year of the Forum they attended, the duration of their stay in office, gender and

their availability for interviews. Another important criterion was the portfolio or

capacity the Ministers were serving under at the time of the interview, either in

government or any capacity outside of government. Of the ten ministers, six are still

in office as finance ministers whilst the other four are former ministers. There were

seven male and three female participants. The selection criteria enabled the

Evaluator to draw on a range of experiences from diverse contexts, and collectively

the combination of both former and serving ministers provides the opportunity to

examine the relevance of the Program to both the serving and former ministers.

The selection criteria had some inherent weaknesses that might have inadvertently

affected the evaluation approach. The Ministers attended different Ministerial

Forums and they had spent differing periods holding the finance portfolios. Some of

the participants attended the Forum in April 2017 and due to the relatively short

intervening period between their return from the Forum and the evaluation

interviews, some of them had not fully implemented the principles from the Forum

or fully realized the outcomes of their initiatives. In some instances the respondents

had been moved to different ministries or spent relatively short periods within the

Ministries of Finance and in such cases the impact of their initiatives, particularly in

terms of the outcomes, are difficult to decipher. The Evaluator however mitigated

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this weakness by inquiring how the informants were applying the principles they

learnt in their new portfolios or roles. In a way, this speaks to the broader impact

and utility of the Program in enhancing leadership capabilities beyond strengthening

health sector performance. In cases where the participants were no longer holding

government positions, the interviews offered them a platform to share richer

reflections of their time in office without the strictures of government office and this

in some ways enhances the quality of the findings and analysis provided in the

report.

The evaluation process was also affected by the fact that some of the informants

were either moved from the finance ministry through Cabinet reshuffles or lost their

positions following elections. In such cases, the outcomes of their initiatives as well

as the impact of changes they instituted are not obviously apparent.

The findings and analysis presented in this report should be contextualized and

understood within the broader contexts the different participants are located. The

implementation and application of certain principles and approaches was, at times,

mediated and impinged upon by circumstances outside of the finance ministers’

immediate control. Such factors included economic recession, which directly

affected resource mobilization and allocation. In the case of some of the West

African countries, the health systems were severely affected by the Ebola virus

which placed a massive strain on infrastructure and budget allocations. While these

circumstances affected the finance ministers’ abilities to plan, it also enabled them

to demonstrate political acumen and leadership effectiveness in difficult

circumstances, and the report attempts to bring out these qualities and abilities.

The analysis presented here is not generalizable to the countries whose ministers

participated in the Program; rather its main aim is to provide detailed insights drawn

from the perspectives and experiences of the ten key informants.

In the report the ten ministers are referred to as key informants, participants,

ministers or respondents and these terms are used interchangeably.

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The questions posed to the ten respondents are listed below:

1. How did your participation in the Harvard Program impact on your role as

finance minister generally? More specifically, do you think you were a more

effective leader after participating in the Harvard Forum? If yes, how specifically

were you more effective?

2. The Program encourages health and finance ministers to collaborate to

strengthen health sector performance. Were you able to collaborate with the

health minister? If so, what results did this produce? If not, why not?

3. The Program places a strong emphasis on health budget effectiveness and

efficiency as a driver of health system strengthening (e.g. increasing fiscal space

in the health budget through budget reallocation, cost savings, efficiency,

increasing domestic revenue, public-private partnerships). Did the Program have

any impact in helping you leverage health budget effectiveness and efficiency to

improve health system performance? How specifically?

4. Please describe TWO or more specific initiatives arising from your participation in

the Harvard Program that you have implemented. How would you describe the

enduring impact of these initiatives?

5. [Asked in the case of seven countries that participate in the follow-up component

of the Program.] Regarding the participation by the joint health-finance Senior

Leadership Team in the follow-up support provided by the Program: Did this

have any tangible benefit to you in implementing your key priorities? How

specifically did the Team contribute to implementation of your priorities?

6. Reflecting on your term in office, how would you describe the enduring value of

your participation in the Harvard Program? Would your record in office have

looked any different if you had not participated in the Harvard Program?

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3. Findings and Analysis of Ministers of Finance Interviews

This section presents the analysis of the interview material. The data show how

these ministers’ participation in the Harvard Program affected their perspectives and

roles as finance ministers, particularly in their engagements with the ministries of

health. The analysis also explores the ways in which these finance ministers

responded to the notion of collaboration with their health ministers to improve

value for money and achieve better health outcomes, and whether they extended

The Harvard Program approaches beyond the health sector. The material analyzed

here also details the initiatives the participants undertook to mobilize resources and

whether the resources were used more effectively and efficiently to strengthen

health sector performance. The main thrust of the analysis is to highlight how the

Program goals, principles and approaches were translated into systems, processes

and outcomes, and how these impacted on or enhanced the performance of the

health sector and affected the actions of the health ministers.

In the first instance and in the subsequent section the report focuses on how these

finance ministers learnt about the importance of strengthening health systems to

produce improved health outcomes.

i) The role of finance ministers in strengthening health systems

In the interviews the respondents highlighted that a key principle they learnt from

the Program was the need to strengthen health systems in order to ensure improved

health outcomes. The ministers stated that the Program emphasized how the health

sector was imperative in a country’s development and how they could achieve

success and value for money in financing health care through prioritizing Primary

Health Care and universal access to health. Six out of the ten ministers stated that

they had prioritized Primary Health Care and universal access to health care and they

viewed affordable and accessible health care as important to development.

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A relatively new finance minister (Minister 5) stated that he now understood the

need to create an affordable health care system, and that his role was to prioritize

the health sector and restructure the administrative systems so as to ensure health

care was affordable. He stated that his target was to: ‘work through the budgeting to

make sure things are in line with the needs and the health policy to have an

affordable healthcare system.’

The interview material highlights that there are various ways the ministers sought to

establish such affordable and accessible health care systems. For example:

Finance minister 2 revealed that through participation in the Forum she came to

appreciate the need to invest in primary health care, because doing so not only

strengthened health systems in her country, but offered value for money in the long

term. She came to the realization that primary health care would undergird her

country’s economic wellbeing through providing a much more productive workforce

as well as lowering expenditure in the health sector in the long run. Her country

structured national health systems ‘in such a way to give the necessary relevance to

primary care’. She stated that :

We managed to implement a health system in which the primary care is an important one. By following the Harvard Program, it became clear that I was doing better from an expenditure optimization standpoint. The Harvard Program helped me to see all the aspects of having a health system in which primary care is one of the first pillars. And that was that fact that you can have an impact on economic growth, on workforce productivity and also have a very good impact on the value chain on expenditure in the health sector, because when you invest more in the primary care, down the road you will of course use your financial resources more efficiently. So for example, if for ten years you invest in primary healthcare, this is a long term investment. Short term strategy does not work for this approach.

Former health minister 9 stated that after his participation in the Program he

prioritized universal health care through both the development of a National Health

Insurance (NHI) policy as well as promoting a coordinated approach to health care

provision through improving health services offered in public facilities:

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With universal health, we have this platform that we are talking about – you need to pool resources, you need to improve the quality of the public health facility such that people don’t have to run to the private facilities in order to get a better service. So you need to improve the quality of service in those. But you also need a legislative framework like we have got the NHI policy in place. So you do need universal access as well, but you do need a coordinated approach with the private sector playing a role together with government to promote such a coordinated approach.

Respondent 6 revealed that his participation in the Program strengthened his

resolve to be a ‘transformative' leader and in his case this partly took the form of

prioritizing primary health care. Within prioritizing basic health care, he aimed to

make an impact on the most critical aspects:

What do we look out for in the case of the country’s healthcare system? Do they have issues of maternal mortality rate that are very high, do we have a situation of infant mortality rate that is also high, then the question is yes, in terms of an answer, for which the resources must be targeted in a way that says, can we strengthen the healthcare system in a way that addresses mortality rates, be it for maternal, be it for infants? So in that way, we can rather take money and put it where the maximum results are needed rather than say, oh in healthcare, can we focus on all of the issues. Do we need more of polio vaccine or do we need more of healthcare results in the area of reducing mortality rates related to mothers and infants? So it is that sort of way of achieving in obtaining what is best needed for our setting.

Following their participation in the Harvard Program, ministers appreciated the

importance of the health sector in their respective countries’ development. Some of

these ministers actively financed primary health care systems and promoted access

to universal health care in recognition of the important role the health sector played

in development.

ii) Finance ministers’ changing perspectives of their roles

All ten participants stated that the Harvard Program was useful in changing the ways

they perceived and understood their leadership roles as ministers of finance as well

as the role that the finance ministry plays - not only in fostering economic

development, but in strengthening health sector performance as an essential

investment for economic growth. In practical ways, respondents highlighted that

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after participating in the Program’s Ministerial Forum, they began to prioritize their

goals in a much more focused manner. They also changed their perception of health

ministry spending - from consumptive units to a sector requiring investment.

Finance minister 3, currently in office, stated that the value of the Program lay in the

manner it improved his understanding of performance management, particularly the

importance of setting priorities:

I can now make a list of priorities that are a significant conclusion to policy goals that we have set. So prioritizing tasks … and mobilizing my staff around these priorities, focusing more on implementation and results. It has been more results driven, focus oriented.

Following his participation in the Program this minister revealed that he had

changed the planning process in government, and instituted a monitoring system

that tracked progress in different sectors. In this country the Harvard Program thus

had an influence that extended beyond the Ministry of Health to other ministries,

through the new monitoring system introduced by the Ministry of Finance:

I have changed the annual planning process. Now we have an action plan for ministries. It is focused and clearly sets the key priorities for the year. We have indicators and milestones. I have also put a clear system for monitoring progress, performance and results. So the monitoring system is the focus right now within my ministry.

Finance minister 8 stated that the Program reaffirmed what he previously believed,

which is that sectors such as health and education should be prioritized in resource

allocation, as these are essential for human development:

The Program was [helpful to] refocus attention, maybe narrow in specific areas, which are critical to the progress of one’s society - focusing on education, focusing on health, making effort to make substantial [investment]. But for me personally, this was just a reinforcement of what I believe, of how I think we should approach development.

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As a result of his participation in the Harvard Forum, he stated that his ministry

introduced legislation to institutionalize a new way of conducting business,

especially to help ministries prepare budgets, prioritize key areas of expenditure,

and discourage resorting to supplementary budgets except for emergencies:

Well, you know historically, the Ministry of Finance had evolved itself into a super ministry. Since I came in, we have pushed in the Public Financial Management Act (PFMA), which is going to replace the Government Budget and Accounting Act. We now have a new way of doing business and one of the challenges is helping ministries to prepare realistic budgets because of the notion of priority; we are now working on the rules and regulations. The notion of extra budgeting is out - except for absolute emergencies like we had with Ebola or like if we have an earthquake or storm. You have to get your priorities right. If you have five priorities, rank them.

All ten finance ministers stated that their perceptions of the role of the Ministry of

Health (MoH) was changed or transformed during their participation in the

Ministerial Forums. Prior to their participation in the Forums, a widely-held view

among the participants was that health ministries were consumptive in that they

made little if any contribution to economic development. After attending the

Ministerial Forum, these perceptions changed completely: in all the ten countries,

financing health care was increasingly perceived as a necessary investment for

development. The participants’ changing perceptions of the health sector resulted in

them changing their leadership styles and engaging their health ministers.

For example, former finance minister 4 stated that the Program changed his

perception of the health ministry, and this resulted in him changing the manner he

engaged and interacted with officials from the health sector:

I think the Program has been very useful certainly because one, I have learnt new things and, two, the participation has improved my understanding of the health sector and also therefore increased my participation and interaction with the health sector personnel. The perception I used to have [of the Ministry of Health] has changed significantly from how I used to see them before the Program. Initially, you see them more as people who want to spend money for the sake of spending. But after participation in the Forum I got a better understanding of what the health sector is all about and how as the Minister of Finance I can participate in ensuring

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better outcomes improvement with the resources that have been allocated – how to strategically and effectively use those resources. Certainly before that [participation in the Ministerial Forum convened at Harvard University], health was seen more as a spending unit and we were not seeing it in terms of its contribution to economic growth.

Former finance minister 4’s views resonated with those of key informant 9, also a

former minister, who highlighted that resources spent on health (as well as

education) were a form of investment that improved the quality of life for citizens:

The understanding that health and education - always take the two together: that is where you always find almost all of our HDI indicators. So it is an investment, but of course there are other competing needs – but it talks to a broader program of improving the quality of life of people in terms of life expectancy, looking at literacy, looking at child mortality, and stuff like that. So all of those things you begin to realize that unless we have some understanding of where we fit them in the broader government agenda, we have the tendency of just talking resources.

Finance minister 1’s views about her participation in the Harvard Program are

particularly instructive and resonate with the views of the other participants. The

Program enabled her to see resource allocation to the health sector as a form of

investment, and that as the Minister of Finance she could also engage in discussions

around the health sector especially on how to invest more strategically in the health

sector:

In the past people used to consider that ministers of finance do not need to be involved in discussions on the health sector. It was considered [a domain] for medical doctors; but due to my participation in the Forum in Harvard, I began to engage in very interactive and productive dialogues with my colleagues in the Ministry of Health. Particularly, it is not only about saying that health is expensive, but it was about saying that if we invest in health we will get a return on our investment. It was also the demonstration that investing in health can also give us a long-term development perspective in our country. Number three, with the exchanges with peers, it also gave me the opportunities to see that we can invest more strategically in the health sector. It is not about spending more money. It is about spending better money with very good services etc.

One of the participants, former finance minister 10, revealed that her participation

in the Harvard Program led to a greater understanding of the importance of

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financing the health system, and ultimately this led to health reform in her country

through the introduction of national health insurance in order to extend access to

health care services to all the communities within his country. She stated that her

leadership was instrumental in the introduction of a national health insurance

program, which she sees as her legacy:

My participation in the Harvard Program made me realize how important health financing could be for the wellbeing of the people and for the economy at large. The healthier the population the more the economy grows- at least that is the hypothesis. It made me participate in ministries of health inner programs. It even came to a point where as a government we realized how important it is for the people to have access to better health services. The government is in the process of ensuring that all the people in the communities have health insurance which I could also say was part of my intervention. Now we are in the process of ensuring that every community in the villages and in towns has health insurance. I am very proud of that because I also contributed to that- to the thinking and to the reform - it was because of my participation in the Harvard Program.

For respondent 8 the Harvard Program’s focus on education and health affirmed

what he perceived as critical priorities in society, but from the Program he learnt to

manage competing demands and to prioritize these two areas as key investments

into human resources:

Well you know the Program was helping you like refocus attention, maybe narrow in specific areas, which are critical to the progress of one’s society - focusing on education, focusing on health, making effort to make substantial - what you call down payment for your house. Then the leadership from that point becomes how you manage it, because you face naturally as Minister of Finance, fiscal demands all over you and you have to sit down with the staff and make a case for putting more money always in education, putting more money in health. But for me personally, this was just a reinforcement of what I believe, of how I think we should approach development.I think the course allowed you to - for me personally - reinforce your belief, how to spend money, how to invest in your human resource because at the end, that is really what you have.

While many of the participants began to see health care as an investment rather

than unproductive spending, one of the ministers, respondent 3 saw his role

broadened to improving the efficiency and effectiveness of the public financial

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management system in the country within public entities, mobilizing resources and

applying prudent financial systems:

So one is improving efficiency and effectiveness of government budget. Broadly, I am trying to strengthen the public financial management system in the country with the objective of improving budget efficiency allocated to the different parastatals. That is the key priority. Then I am responsible also for administering fiscal policy, so creating a prudent fiscal system that supports inclusive economic growth, through mobilising resources, tax revenue and other resources to support our development programmes.

In general the interview material shows that the MoF’s participation in the Harvard

Program changed their perceptions of their leadership roles within the government

and their countries at large. These changing perceptions also transformed their

leadership and strategic roles. The section below examines the ways in which the

leadership responsibilities of the Ministers changed and the manner this change

impacted on their respective countries.

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iii) Leadership in relation to strengthening the health sector

According to the interview data, the finance ministers’ leadership roles in relation to

health were affected as a result of their participation in the Program. All ten key

informants revealed that the Program helped them to perceive their responsibilities

as encompassing the need to demand greater accountability from fellow ministers.

Significantly, their participation helped change the way they led their ministries, and

it also changed the ways in which they understood their strategic roles as Ministers

of Finance.

Among some of the changes the participants initiated was the adoption of a results

based approach in carrying out government functions, duties and responsibilities. A

key output in three countries was the realization of the importance of national

health insurance policies and in two of these three countries processes for the

establishment of national health insurance policies were initiated to extend the

provision of universal health care. The interview material shows how the

interviewees’ leadership and strategic roles varied, depending on what they

perceived as key priorities in their specific contexts. This section casts attention on

what the ministers did in order to strengthen the health sector.

Participant 5 stated that the Program was essential in enabling him to work towards

the development of a new economic policy, the National Development Plan (2017-

2020), creating management teams within Cabinet as well as setting up new

management systems that included holding regular meetings, instituting reporting

systems and mechanisms, and introducing performance evaluation for staff:

The Program broadened my vision on how to work as a finance minister and [with] the rest of my Cabinet ministers to get the economic transformation that they are looking for. Right now we are developing our national development plan for 2017-2020. At the ministerial level in terms of leadership, we have been able to build a management team. Previously there were no such meetings [between ministers and] permanent secretaries and directors. Now we have monthly meetings. We have monthly reporting as well and we are developing performance targets and we will develop performance evaluation of staff. So [the Program] has changed the

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work culture of the ministry and the staff is adjusting to that. I think it is more effective than the previous set up that I found here.

For Finance minister 6 the value of the Program was in its ability to strengthen the

health system not just through directly financing the health sector, but through

reallocating resources to other sectors in a manner that supports and strengthens

health care such as improving access to clean water and sanitation for communities.

He revealed that:

In the area of healthcare, especially on the watch is water and sanitation. What are the issues there? We have close to 60% of the population that doesn’t have access to good drinking water, don’t have better access to sanitation facilities in terms of toilets. There is a need to improve - so it is in that context that the strategic focus of resource allocation must be address specific needs as a country. So that ends just here. So my situation is a combination of infrastructure, health and education. So those are the three focal areas.

One of the former ministers, respondent 9, also saw his role of finance minister as

one of making strategic allocations to other ministries, such as those of education

and social development, whose programs directly and indirectly support the health

ministry. He also pointed to the importance of investing in employment. The

approach he adopted had wider applicability beyond the Ministry of Health, and

would support the priorities of the health minister:

At times people just think that it is the allocation of resources that will solve problems and yet in most cases it is about making sure that the resources are spent efficiently, are spent in areas where they would have the greatest of impact. If you look at our resources in this country you will realise that health has one of the largest budgets. But all in all, I think it is important to always have a fuller picture, so that when you are allocating resources in health, you are not just allocating them in health but also allocating in other departments that work closely with the Department of Health. I have mentioned education. Social development is also one of those, but also investing in areas that create employment, because in the absence of that, you have people that are not in a position to be able to afford healthcare.

During his time in office as the head of Treasury, the minister contributed to the

development of the National Health Insurance policy (NHI).

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Finance Minister 6 said that the Harvard Program enabled him to see his role as that

of demanding greater accountability from other government ministers as a means of

improving budget efficiency and overall performance:

In the context of performance when you are coming to us, you have to come with your report in terms of what was achieved from the previous allotment made to your given sector. So the activities you implemented, what were the outcomes - that sort of performance-based, sort of grading of your performance is what will inform us of how we are making additional allocation to your ministry or a given sector.

Finance minister 8 revealed that in his country the finance ministry went beyond

resource allocation to holding other ministers accountable in a manner that curbed

wastage – for example, by cleaning up the health payroll and reallocating the savings

made to areas of need.

The Minister of Health easily bought into my project proposal because I sat down with him and his staff and I asked my accounts people to print the whole payroll. I literally sat down with him, as well as the the Chief Medical Officer and went through some of the payroll and realized that we needed to substantially clean the payroll, which was essentially one of the projects I was proposing - to the effect that if we clean the payroll, the money saved can be ploughed back to more effective use of the Ministry of Health - it could be a better way to utilize the Ministry of Health resources. So in fact, even as I sit here, this is one of the four things in my mind to put up a program to clean the payroll - I don't think that payroll is real.

Finance minister 1 revealed that her country was allocating resources to achieve

specific health outcomes despite the scarcity of resources. In this case resources

were allocated to support reproductive health for young women:

[In the] new budget that we have prepared for 2018, my hope is to see that it is very result oriented in the health sector. And the good news that I also want you to know, [country 1] here in our region … has earmarked for 2017, 500 million local Francs which is about 1 million in USD to invest to reproductive health, because we have realized that despite the scarcity of resources, we see that investing in health, particularly in the health of young women, we will really get value added in the development of our country.

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In general these ministers and former ministers demonstrated leadership and

political acumen through supporting the introduction of national health insurance

policies that would extend health care access and ultimately improve and strengthen

the health delivery system. The participants also began to hold fellow cabinet

ministers accountable for budget allocations in order to promote fiscal discipline and

increasing the fiscal space. In the section below the report details how Ministers of

Finance collaborated with Ministers of Health as well as other ministers, and in what

ways some of the principles and lessons learnt at the Harvard Program were applied

to such collaboration.

iv) Collaboration between health and finance ministers to strengthen

health sector performance

A key observation that emerges from the interviews is that after attending the

Harvard Ministerial Forums, these finance ministers engaged and collaborated with

their Ministers of Health as well as other Cabinet ministers. In countries where both

the Ministers of Finance and Health attended the Program, there was increased

collaboration and synergy between the participants and their ministries, and this

was beneficial particularly in enabling them to devise their plans, and articulate

more rigorous procedures and systems.

Nine out of ten interviewees stated that their collaboration with their health

ministers was productive, and helped them to achieve their goals. For three

respondents these outcomes included introducing the national health insurance

programs, reforming procurement systems, and creating priority lists that

channelled resources to areas of greatest need.

In one case the finance minister did not manage to collaborate with the health

minister because of a Cabinet reshuffle, and at the time of the interview the two

ministers had not yet met. One finance minister collaborated with his health

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counterpart, but encountered resistance from officials working within the public

administration structures who struggled to adjust to reforms.

Finance minister 3 stated that after attending the Harvard Ministerial Forum, he

started collaborating with the health minister and a key outcome that emerged from

this collaboration was the drafting of a social health insurance system:

We started collaborating with the minister of health. We actually decided to focus on the newly launched social health insurance system. The government just drafted a policy introducing a social health insurance system. Myself and the minister of health agreed that I can introduce some of the things I learnt at Harvard in the social health insurance.

Key informant 4, a serving finance minister, stated that the finance ministry’s

collaboration with the health ministry precipitated changes to the procurement

system in order to make it more efficient and effective. In collaboration with other

government partners, he proposed a change from a single source procurement

system to an international competitive system. The ministry of health was able to list

the essential drugs the country needed and it is anticipated that these changes will

improve access to drugs and health care:

We are beginning to collaborate. The health sector faces numerous challenges, very difficult challenges in the procurement system and the distribution system of drugs throughout the country. So we really want to support them to change the procurement system to make sure it is more efficient and effective. So currently with the World Bank also insisting on it, we were able to change from single source procurement to an international competitive system. [The health ministry] were also able to come up with a list of essential drugs. But still the challenges are numerous. Right now resources are limited - so that really increases difficulties in solving these challenges. But the collaboration has begun and we really look forward to changing the health sector with the primary health care system, and improving access to drugs. With the previous regime everything was order, command and directives. So that is why we had single sourcing entrenched in it. We are beginning to pull together again to have an impact.

In the case of former finance minister 2, her participation in the Program produced a

much stronger relationship with the Minister of Health, which ensured that they had

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common goals, and better articulation of their efforts in managing health

expenditure whilst optimizing health revenue. While in office and for two successive

years she managed to increase the health budget while the ministry of health

managed to eliminate wasteful expenditure:

The best results as Minister of Finance at the Harvard Program has been the fact that my relationship with the Minister of Health has been much better organized and together we have been able to work in such an articulated way having a common goal in our health expenditure, but at the same time trying to optimise health revenue.

We have been able to do a sort of agreement. So I would try to increase the health budget, no problem; but at the same time, the Minister of Health had to prove that she managed the same budget more efficiently and in a more optimized way. She implemented all reforms. She was able to eliminate wrong and bad expenditure. She was able to optimize health expenditure. At the same time, the budget of health has been increased twice – in 2014 and 2015. The Program put us together in the same analytical framework with a very strong monitoring by the Harvard University, and more than that working together in a team approach.

In participant 9’s country where both the finance and health minister attended the

Program’s Ministerial Forum, the former finance minister observed that there was

greater synergy and cooperation between his ministry and that of the health

ministry. The finance minister stated that:

I found that we were more in sync than we were before I went. Indeed we had a good working relationship even prior to that, but we were much more in sync because he had also attended the one for health ministers. That helped a great deal. And I think in our processing of position papers, we were very much aligned than we were prior to the Program. We exchanged experiences; that is where we enriched each other’s understanding.

The interviews show that although most of these finance ministers collaborated with

their health ministers in ways that produced some favourable and positive outcomes,

some also had to contend with instances of resistance, particularly from the wider

political sphere. For example, in country 2 the former finance minister stated that

reforms she instituted to bring about accountability and efficiency were initially

resisted, because of her insistence on greater transparency, efficiency accountability

and control:

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I faced strong resistance because the expenditure side of the reform was guided by more transparency, more accountability which means more control. Let me give you an example: Before, all school budgets for each school was out of the budget. During my time and because of the reforms, all budgets for schools were fully integrated [into the budget].

Since I developed a strong technological platform, expenditure was processed within the system - not manually, but within the system following five steps. These five steps involved the sectoral ministry and the last three financial ministers, and thousands and thousands of staff from public administration. As you can imagine, these are kind of reforms people do not expect very quickly. So I met strong resistance – not because they did not participate in the Harvard Program, but because the reform changed a lot – transparency, accountability, efficiency. Maybe this type of work if it could involve more ministers could be helpful.

In the one instance, finance minister 3 said that although he had not yet been able

to collaborate with the health minister due to a Cabinet reshuffle. In this particular

case the former health minister had attended the Forum in 2013 and officials from

his ministry attended a suppport workshop thereafter. The Minister of Finance then

attended the Forum in 2015 and worked closely with then Minister of Health,

particularly in drafting the social health insurance policy. A cabinet reshuffle resulted

in the departure of this particular health minister in February 2016. Although the

serving minister of health has not shown much support for the Program, the inter-

ministerial technical committees drawn from both the finance and health ministries

are working together:

There is a new minister [of health]. To be honest we have not talked about it. In fact there is a joint team with two senior experts from the ministry of finance and ministry of health working around those areas [of collaboration]. We have not elevated it to ministerial level, but the technical committees are working.

In general in instances where the MoF collaborated with the MoH there were

positive outcomes that resulted in the optimization of the budget and reduction of

wasteful expenditure. In some instances ministers were also able to formulate

policies that facilitated the introduction of national health insurance that would in

the long term extend access to universal health care. Some of the systems

introduced include results- and performance-based systems of budgeting and

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resource allocation, the creation of management teams within cabinet and the

setting up of new management systems with regular reporting and monitoring

mechanisms. Newly introduced processes included the prioritization of health

programs and activities, the allocation of resources to ministries that supported the

health sector, changing procurement systems and upgrading health facilities in order

to curb the use of foreign currency in overseas medical institutions. Some of the key

outcomes the audit of health payrolls, changes in procurement systems and the

optimization of health expenditure.

The following section examines the ministers’ initiatives to utilize health budgets

more effectively and efficiently in order to strengthen health care systems.

v) Budget efficiency and effectiveness

In this section the report details the ways in which the finance ministers sought to

encourage the more effective and efficient use of health budgets in order to

strengthen health systems in their respective countries. The focus is specifically on

how these ministers sought to increase fiscal space, curb wastage, cut costs,

generate revenue, and whether these measures improved health budget efficiency

and effectiveness.

The interviews indicate that six out of the ten participants derived tangible outcomes

from applying the Program approaches, even though they were confronted by

challenges and hindrances. The other four participants subscribed to the principles

taught in the Harvard Program and had implemented these approaches, but by the

time interviews were conducted, the outcome of their efforts was largely

inconclusive.

Finance minister 5 said that his country sought to use the health budget more

effectively and efficiently by adopting new systems, procedures and processes

particularly in health procurement systems. The participant stated that:

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I think the Program will improve and increase the sectors’ efficiencies. The budgeting will try to prioritize health programs and activities. In the implementation we cut down waste through competitive procurement, stress management and distribution to the different health clinics in the counties. So we will work through the budgeting to make sure these things are in line with the needs and the health policy to have affordable health care system.

While this finance minister was introducing reforms, particularly pertaining to the

health procurement systems, the outcomes of the reforms are not immediately

obvious due to the relatively short period he has been in office (since February 2017).

Former finance minister 4 revealed that his country sought to mobilize domestic

revenue to support the health care system through introducing a system of

increasing taxation on tobacco annually:

In terms of additional resource mobilization, one that is very clear is taxation on tobacco. When we came back [from the Forum] I said: one way to raise money is to initiate taxes on tobacco. When I mentioned this to the health minister, he said in fact there is a United Nations framework convention on tobacco control and he said to me it has provisions along those lines. I said look at it and come back with a proposal that we will be implementing on an annual budget. That has happened. Every year when you listen to the government budget, there are new taxes on tobacco that are implemented. I think that is something that I am proud of. The tax on tobacco used to be there, but not on a regular basis. But after the Program, it was institutionalized. Every year, there would be a new tax [on tobacco]. Since we cannot say we are banning tobacco imports, the best thing was to do taxes on an annual basis until we have reached a point where tobacco use has been brought to a minimal level.

Finance minister 8 said that issues of budget efficiency and effectiveness were being

addressed through upgrading two hospitals into specialized units offering high

medical care and in the process saving the country’s foreign currency reserves by

dissuading people from traveling abroad to seek medical care that is unavailable in

their country. The finance minister viewed this as an investment in health care so as

to realize savings on the country’s foreign reserves while simultaneously

strengthening its health delivery system:

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When you are faced with somebody who has been diagnosed with an illness and we cannot do anything, we have to send them abroad and the family depends on you. We spend money on a lot of overseas travel; a lot of requests for medical travel are made both at the private level and government level because what you might call improved hospitals are still basic. So for a country that is trapped with generating forex, you don’t want to be spending monies on people that is meant for us. You have to generate local currency, and then you translate to US dollars, Pounds or Euros, which is a challenge to the budget. It is a challenge to the forex rules in the country. So there are one or two hospitals which really we are having discussions with the minister to upgrade, so that something a little bit more sophisticated work can be done in the capital city before you go abroad. Sometimes you know with all of this if you don’t have the capacity to test for the kind of illness that you have, it is simple to go abroad – go to Ghana, UK, US, India. And that is really a challenge on the budget. So that is one initiative we have to pursue.

Finance minister 6 indicated that his country was prioritizing curbing wasteful

expenditure by identifying and blocking financial leakages manifest in recurrent

expenditure and corruption within the government system. He highlighted that the

government was introducing a new performance appraisal system to curb the

inappropriate use of resources:

55% of our budget is recurrent expenditure. So there needs to be a score to say how many projects have we achieved as a government and if we drop down to sector specific, the same holds true. Some budgets that are allocated across sectors, you find almost 90% for buying cars or the issue of compensation allowances. So in my mind that is an inappropriate way resources are being used and that had become a perennial problem for years.

So at this point in time we are now introducing this performance base that is more resource oriented. So it is now beginning to create some level of traction in a way, I know for others they are hard, some people are saying you are trying to bring to the ministries new rules or we were doing this before, just too many questions. It is not a matter of what you were doing with your previous allocation. So in this way the overall system in terms of resource abuse is one of those things that we are working...especially entrenched corruption. Corruption again is another element in the government system that we are also trying to address.

Former finance minister 9 created fiscal space by changing the procurement system

in the Ministry of Health. By so doing the minister also managed to maintain or

increase resource allocation to the health and education ministries. In addition, by

reducing personnel in non-core areas (e.g. administration), the finance minister

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managed to retain key personnel within the health sector, even though austerity

measures were being applied throughout government:

Health has in a way been benefitting more than other departments in terms of resource allocation. As we were operating under a very tough fiscal situation, we would try by all means to protect allocation to departments like health and education, whilst we were confronted with high levels of wanting to reduce allocations to other departments.

But when it came to personnel, one of the things we would say when it comes to reducing the headcount, we would say – let us identify non-core areas to reduce personnel. You cannot reduce from the nursing, doctors and specialists side. But when it came to administration that is where we would come hard on the department. Some provinces have been increasing their expenditure in noncore areas and employing personnel. So that would be the first.

But again with health, when we introduced the office of the chief procurement officer, we took health as one of those areas we should be able to look at centralized procurement and transfer contracts in order to purchase at reasonable rates. I think it was succeeding. We worked with the Deputy [Health] Minister quite well in that space; the [Health] Minister himself was quite keen to see those savings because savings were going to release the resources for him to be able to implement programs within the health department.

As a result of the cost cutting measures, this former minister revealed that key

significant savings were made that could be reallocated to other areas of highest

priority:

I remember when we started introducing cost-cutting measures in general say around 2014, when we checked the budget in 2015, we were able to report a huge saving across government departments that were not only attributed to health. We are talking about something like R500 million (approximately USD38.5m) at the beginning of 2015, which came about as a result of initiatives we had implemented in 2014. But that is just not health; that would be across [government departments].

Former finance minister 2 described how between 2012 and 2016, she was able to

implement “very deep reforms” which completely changed the political fiscal

framework in the country. During the time she attended the Harvard Program her

country was in the midst of economic reforms that were instituted to increase the

fiscal space in the budget by reducing bad public debt among other measures. She

attended the Forum in 2014 and her experience illustrates the ways in which, as

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Minister of Finance, she was able to increase revenues and create fiscal space that

enabled the country to support the health sector:

In the past from 2012 until 2016, I managed to change completely this political fiscal framework in the country. So I undertook very deep reforms in order to increase revenue and in order to increase the fiscal space. And that was an important strategy that started 5 years before in 2010 when in short what I did – first, I decreased the bad public debt from 88 to 67. I decreased what I considered bad public debt. And then with the framework agreed with the World Bank and the International Monetary Fund Cape Verde increased the public debt. Due to a strong infrastructure Program the country is no longer classified under the Least Developed Country (LDC) it is middle income country. Of course behind this public infrastructure programme, there is public debt. In order not to lose the public finance management sustainability, I had to undertake strong reforms of the revenue side and fiscal policy. So I believe that I took the position to increase revenue and consequently to get more fiscal space for the health sector.

The finance minister highlighted that her country has been able to prioritize primary

health care even in a context where 75% of the country’s budget was provided by

donors. While her response was in relation to the reforms undertaken by her

government in the entire economy, some of these measures had important spinoffs

for the health sector:

To provide you with an example, 75% of our public investment programmes are financed by international aid. In this case when I say aid, I am including of course highly concessional loans to infrastructure the country. We managed to implement a health system in which the primary care is an important one. By following the Harvard Program, it became clear that I was doing better from an expenditure optimization standpoint. The Harvard Program helped me to see all the aspects of having a health system in which primary care is one of the first pillars. And that was that fact that you can have an impact on economic growth, on workforce productivity and also have a very good impact on the value chain on expenditure in the health sector, because when you invest more in the primary care, down the road, you will of course use your financial resources more efficiently. So for example, if for ten years you invest in primary healthcare, this is a long term investment. Short term strategy does not work for this approach.

Finance minister 6 stated that the Harvard Program helped him in creating fiscal

space and reallocating resources to areas of highest priority. In his country he

prioritized infrastructure development, but did so in a way that supported

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livelihoods and health care. The Program enabled him to introduce a results-based

approach and reallocate limited resources in a manner that ensured he attained his

goals:

Coming out of the Harvard Ministerial Forum, it presented me an opportunity to define and ensure that financing of key priorities does bring out the optimal result that we look forward to - one of which happens to be an ability to create fiscal space within the budget. So how can you reallocate resources to bigger goals. So reallocation of the budget in a way that brings about better use of meagre resources, but yet obtaining results that make a meaningful impact on the livelihood of people.

So in our specific case…… we are faced with infrastructure deficit - we need more roads, we need more affordable electricity. So it’s a list of finance emphasis and also an environment that is characterized by high degree of youthful unemployment. So in what way can a budget, even though the budget is of a size of USD600 million - so how do you allocate resources in a more efficient way that can make you say that roads that connect farms to market are built, that can ensure that healthcare is plenty.

So in these specific ways the Harvard Forum is an eye opener, in terms of how the budget can be executed where resources are properly reallocated and you can achieve maximum results.

Six of the ten ministers managed to implement effective and efficient budgets and in

the process created fiscal space. A key strategy that some of the ministers adopted

was to reallocate resources to areas of greatest need, which areas also indirectly

strengthened health care systems. In other countries the respondents alluded to the

challenges they encountered as they endeavored to make their budgets effective

and efficient. The section below elaborates on these challenges.

vi) Challenges in implementing effective and efficient use of health budgets

In some countries, although the finance ministers subscribed to the Harvard

Program approach on how to create fiscal space by curbing wastage and generating

more domestic revenue, efforts at implementing efficient and effective budgets

were hindered by lack of or inadequate financing and resistance by other ministries.

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Former finance minister 10 revealed that while her government had made a

commitment towards an increased health budget this was hindered by the failure to

avail the resources to the health ministry:

In terms of the number [amount], you could see in the budget that the numbers had been increased. But in terms of real disbursements, it has not been increased at that stage. Even now, [the country] is in agreement with other regional and international agreements including MDGs and SDGs, but also [the] Maputo agreement just to increase fiscal space for health. However, given the economic condition in [the country], the demands and the needs, the implementation of it [the National Health Insurance policy] is a challenge because of the challenges in revenue. But we are so optimistic now that there are big reforms, and the overall budget has been increased.

But the budgets are just the numbers. Real implementation is questionable because of the demands. The [country] still depends on international organizations for its budget in terms of commercial loans and non-commercial loans. … last year there was a challenge of provision of this budget from the international donors. So I am pretty sure that even the health budget has been affected by that. So the challenge is not about the strategies. The challenge is about the financing.

Two ministers alluded to challenges they encountered in trying to raise finances for

the health sector through taxation.

Finance minister 3 alluded to the problems of resource mobilization, particularly

taxation systems, as a challenge to raising the required levels of finance to meet

important needs for his country including health care. The minister highlighted that

despite efforts to efficiently and effectively implement the national budgets efforts

were often hindered by the country’s ability to collect revenues.

The size of government budget has increased significantly over the years and it is very important that we make sure that waste is minimised and inefficiencies are improved etc. So even a small saving in terms of efficiency gains says a lot, given the size of the government budget, given also the challenge we are facing in collecting revenue. The economy is growing and becoming more diversified. Big businesses are coming, and collecting tax is becoming more and more challenging. Whatever we collect, it is absolutely critical that we spend it well and we spend it efficiently.

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The minister also stated that some of the challenges he encountered emanated from

sector ministries, which resisted the importance of efficiently and effectively utilizing

allocated funds:

In terms of creating understanding and consensus about the importance of budget efficiency and effectiveness, it was not [so difficult]. But when we started the implementation, some of them resisted. And then you have resistance, challenge, pushback from the sector ministries. We are explaining to them that this is a time for us to optimally utilise our resources

Former finance minister 4 stated that there was a challenge in raising financial

resources through taxation in his country although he had seen the success of such

measures in other countries. In his case he failed to get approval to introduce user

fees at health institutions as well as introducing Value Added Tax (VAT) with the bulk

of the amount being allocated to the health ministry. The minister stated that:

In terms of additional resource mobilization, I have also engaged the Minister of Health and I said the health sector is not only a spending sector. There are areas where additional revenue can be derived in terms of user charges. But there I had a challenge because our boss who is the president doesn’t like charging fees in the sector for so many activities. So it became a difficult challenge to mobilize resources in terms of charges. So we had to find other ways of raising funds in order to finance health spending.

We also looked at VAT, because we considered examples from other countries. Ghana for example has VAT for financing their health insurance plan. We said we could do the same thing but there too I was facing resistance from other corners that this one is at a high level for the country so if I am to earmark anything, it has to be within the existing rates but not additional rate increase. That discussion did not conclude. So if we were going to increase VAT also for the health sector, we would have said 75% of it will go to health and 25% will go to the general basket for all.

In country 9 they encountered reduced donor funding due to economic recession

and in some ways this affected their ability to properly finance the health care sector

in the manner they intended. The minister stated that:

I think we hit a very difficult period where most of the donors were actually winding down rather than extending - not because of the failures in the system, but because

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of the challenges they themselves were confronted with. You will recall also that the other challenge with our country is our classification as a middle income country. So we were seen as a country that can now be able to stand on our own. So you would find that donor funding is another area of real dependence.

4. Concluding observations

A key principle that the ministers learnt from the Harvard Ministerial Leadership

Program was the need to strengthen health systems in order to ensure improved

health and human development outcomes. As a result of this understanding some of

the ministers prioritized primary health care financing, and embarked on initiatives

to promote universal access to health care in order to ensure that the health sector

supported development and economic growth within their countries both in the

short and long term.

After their participation in the Program these key informants perceived one of their

responsibilities as demanding greater accountability from fellow ministers. This led

some of them to change the way they led their ministries, and it also changed the

ways in which they understood their strategic roles as Ministers of Finance. Among

some of the changes the participants initiated was the adoption of a results-based

approach in carrying out government functions, duties and responsibilities.

In instances where both Ministers of Finance and Health participated in the Harvard

Program there was greater synergy and collaboration and this understanding

produced better outcomes than in cases where only the finance minister had

attended the Program.

These finance ministers sought to increase fiscal space, curb wastage, cut costs, and

generate revenue – measures that collectively aimed to improve health budget

efficiency and effectiveness. In many instances, the ministers were able to create

fiscal space and allocate additional resources to the health sector. However, some of

the ministers encountered challenges in mobilizing resources through inefficient tax

32

collection systems, political resistance and reduced donor support, among other

factors.

While participants generally subscribed to the Program approaches, some

encountered external political hindrances to their implementation, such as cabinet

reshuffles and electoral processes through which some lost their positions. In some

cases factors such as economic recession hindered the ministers from implementing

their goals.

Overall, these ministers introduced the following notable systems, processes and

outcomes: results and performance based systems of budgeting and resource

allocation, the creation of management teams within cabinet and the setting up of

new management systems with regular reporting and monitoring mechanisms.

Newly introduced processes included the prioritization of health programs and

activities, the allocation of resources to ministries that supported the health sector,

changing procurement systems and upgrading health facilities in order to curb the

use of foreign currency in overseas medical institutions. Some of the key outcomes

include the audit of a health payroll, changes in procurement systems and the

optimization of health expenditure. Collectively, these systems, processes and

outcomes led to the strengthening of the health care systems in the different

countries.

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