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Ministerial Leadership in Health Program

An analysis of effects attributed to the Ministerial Leadership in Health Program

by participating health ministers

through focus groups, interviews and a mini-survey

In association with Big Win Philanthropy and with the support of

the Bill & Melinda Gates Foundation

Report compiled by

Helene Perold

with Dr Marinda Weideman

Helene Perold &Associates

25 June 2016

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Contents

1. Introduction .................................................................................................................................... 3

2. Overview of findings ....................................................................................................................... 3

3. Methodology ................................................................................................................................... 4

4. Profile of respondents .................................................................................................................... 5

5. Findings ........................................................................................................................................... 6

5.1 Transformational leadership ................................................................................................... 7

5.2 Organizing for policy implementation .................................................................................... 9

5.3 Health financing .................................................................................................................... 11

5.4 Transferability and continuity of skills .................................................................................. 15

Conclusion ............................................................................................................................................. 16

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1. Introduction The Ministerial Leadership in Health (MLIH) Program is a joint initiative of the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School of Government. Launched in 2012, the Program aims to increase ministerial leadership and effectiveness in strengthening health systems and improving health outcomes in developing and emergent countries. It provides analytical tools and practical ideas for improving standards of public health care by achieving greater efficiency in health resource utilization. One of the features of the Program is nurturing continued peer networking among the MLIH ‘alumni’ by reconvening participants annually. On May 22, 2016 all health ministers who are currently part of the Program gathered at an MLIH Roundtable meeting in Geneva to discuss new ideas and share experience in dealing with challenges encountered in strengthening the health sector. Focus groups and interviews were conducted by an independent evaluator with a number of the Geneva participants as part of a three-year evaluation of MLIH Program impact, and a short written survey was completed by 76% (22) of ministers at the Geneva Roundtable meeting.

2. Overview of findings Respondents indicated that the three aspects of the MLIH Program that made the most impact on

their role as health minister were: (a) transformative leadership (15 out of 22); (b) organizing their

ministries for the implementation of their health priorities (13 out of 22); and (c) health financing (10

out of 22 (see graph below). This suggests that over the years (2012 – 2015) all three pillars of the

Program have had positive effects on these participants.

Former and current health ministers from 14 countries attribute a number of their health reforms

directly to the influence of the MLIH Program. One of the most substantial impacts seems to have

been on the ability of

some countries to make

progress towards

Universal Health

Coverage, as evidenced

by the accounts from

Ghana, Kenya,

Philippines, South

Africa and Taiwan.

Other examples of the

systemic changes in

health include

rebuilding the health

system in post-conflict

Côte d’Ivoire, reforming

the pharmaceutical

supply chain in Kenya, rebuilding confidence in the Mozambique public health system, achieving all

the MDGs in Cape Verde, passing a stricter and more extended food safety law in Taiwan and

improving the quality of care in its remote areas.

The ministers’ accounts indicate that by applying the skills and tools developed through the MLIH

Forums they were able to better organize their ministries, and improved their management and

monitoring of performance. This emerges as a key success factor in achieving the systemic reforms

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10

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13

15

0 2 4 6 8 10 12 14 16

I use data and monitoring routines to…

Together with the Minister of Finance, I…

I hold officials accountable for the…

I was able to implement more effective…

The health budget increased from…

It led to better collaboration between…

Increased my effectiveness in leading…

Increased my ability to set my legacy…

Enabled me to better organize, manage…

Ways in which the MLIH program impactedon respondents' roles as Ministers of Health

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mentioned above, and in securing higher levels of health financing from government funds and from

donors.

Increased fiscal space for health reform was achieved by closer cooperation between the health

ministers and their finance ministers. This included reallocating the health budget more effectively,

and using health resources more efficiently. Examples come from Cape Verde, which reduced

wastage by 30- 40%, and four countries which achieved health budget increases of 2% (Côte

d’Ivoire), 18% (Jamaica), 41% (for malaria elimination in Namibia), and approx.900% (Myanmar).

Despite these positive results, the data suggest that more work is required to achieve similar health

financing gains in a larger number of countries. Similarly, the MLIH Program needs to find ways of

assisting more health ministers to practice evidence-based decision-making, and to strengthen

accountability levels among their officials for the efficient use of health resources and health service

delivery.

Finally, the data suggest that the skills and approaches advocated by the MLIH Program are

transferable to contexts beyond the health sector. The ministers recounted how they have used

their MLIH experience in other government departments, in other capacities in government, and

outside government in private health care and in training students of public health.

3. Methodology Three separate methods were used to collect the data analysed in this report:

Four focus groups were held, involving participants from 14 countries: Algeria, Benin,

Burkina Faso, Cape Verde, Ghana, Jamaica, Kenya, Lesotho, Malawi, Mozambique,

Myanmar, Namibia, the Philippines, Taiwan.

Two in-depth interviews were conducted with participants from Côte d’Ivoire (current

health minister) and Cape Verde (health minister until March 2016).

A short survey was conducted with all 29 participants present at the round table discussion,

and yielded 22 responses – a response rate of 76%. See Table 1 for countries represented in

the survey response.

The findings are self-reported and, given the small number of respondents, they cannot be regarded

as statistically valid. Essentially they record the perceptions of the respondents recorded through the

three different methods used to collect this data.

It is important to note two issues in relation to analyzing this data.

First, participants were asked to select three out of nine competencies that they

consider to be most impactful. Since their selection options were limited, the absence of

selection of other impacts does not mean that these had no effect. It simply means that

the selected effects that they felt made the most impact on their leadership.

Second, although the MLIH Program has since 2012 consistently focused on developing

transformative leadership, in 2015 it introduced a stronger emphasis on health financing

as a driver for strengthening health system more efficient and effective health service

delivery. This may account for some of the trends that are evident in the analysis below.

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4. Profile of respondents Twenty-two participants from 19 countries responded to the ministerial survey. All 22 participants

were, or had recently been, Ministers of Health in their respective countries. Sixteen participants

were from Africa, two from the Caribbean, and four from Asia (see Table 1 for countries

represented).

Table 1 Countries represented in ministerial survey response

Africa Caribbean Asia

Algeria Barbados Georgia

Benin Jamaica Myanmar

Burkina Faso Philippines

Cape Verde Taiwan

Ethiopia

Ghana

Kenya

Lesotho

Liberia

Malawi

Mozambique

Namibia

South Africa

Most of the respondents (32%) had served as health minister for four years or more and 23% had

served for three to four years (see Table 2).

Table 2 Respondent length of service as health minister as at 2016 (n=22)

Length of service as health minister No of respondents Percentage

Four years or more 7 32%

Three years or more, but less than four years

5 23%

Approximately two years 3 14%

One year and up (but less than two years) 2 9%

Less than one year 2 9%

No response 3 14%

Total number of responses 22 100%

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5. Findings The ministerial survey presented the health ministers with a list of options (see below) about the

ways in which the MLIH Program impacted on their role as health minister. Participants were asked

to select the three outcomes that had the most impact. The indicators were:

Increased my ability to set my legacy goals and define priorities for my tenure as Minister.

Increased my effectiveness in leading and delivering transformative efforts for strengthening

health service delivery and improving outcomes.

Enabled me to better organize, manage and monitor performance within the ministry to

ensure implementation of my priorities in health.

I use data and monitoring routines to track progress and outcomes.

I hold officials accountable for the efficient use of health resources and health service

delivery.

It led to better collaboration between me and the Minister of Finance.

The health budget increased from government resources (not only donor funding).

I was able to implement more effective allocation of the health budget and achieve greater

efficiency in health resource utilization.

Together with the Minister of Finance, I identified fiscal space in the health budget in

support of my top priorities in health.

Figure 1 demonstrates in rank order the areas in which the respondents felt attending the ministerial

forum had the most impact.

Figure 1 Self-reported impact of MLIH Program on respondents’ roles as Ministers of Health (n=22)

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9

10

13

15

0 2 4 6 8 10 12 14 16

I hold officials accountable for the efficient use of healthresources and health service delivery.

I use data and monitoring routines to track progress andoutcomes.

Together with the Minister of Finance, I identified fiscalspace in the health budget in support of my top priorities…

I was able to implement more effective allocation of thehealth budget and achieve greater efficiency in health…

The health budget increased from government resources(not only donor funding).

Increased my effectiveness in leading and deliveringtransformative efforts for strengthening health service…

It led to better collaboration between me and the Ministerof Finance.

Enabled me to better organize, manage and monitorperformance within the ministry to ensure…

Increased my ability to set my legacy goals and definepriorities for my tenure as Minister.

Ways in which the MLIH program had an impact on respondents' roles as Ministers of Health

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5.1 Transformational leadership Transformational leadership emerges as one of the top three benefits for the majority of these

respondents. When asked how their participation in the Harvard Program impacted on their role as

health minister, the survey participants responded as follows:

Over two-thirds of the respondents (68% -

15 out of 22) said that participating in the

MLIH Program had ‘increased my ability to

set my legacy goals and define priorities

for my tenure as Minister’.

41% of the respondents (9 out of 22)

indicated that attending the MLIH Program

‘increased my effectiveness in leading and

delivering transformative efforts for

strengthening health service delivery and

improving outcomes’.

These results suggest that the Program was

able to provide these health ministers with the

motivation and skills to formulate legacy goals

that could strengthen the health system in

their country, and equipped many of them to

implement their vision by achieving priority

outcomes.

The focus groups and interviews provided examples of priority initiatives taken by the health

ministers who attribute the outcomes to the influence of the MLIH Program. They range from

rebuilding a health system in post-conflict Côte d’Ivoire, reforming the pharmaceutical supply chain

in Kenya; restoring stakeholder confidence in Mozambique’s goals for its public health system; to

working to implement Universal Health Coverage in Ghana, Kenya, the Philippines, South Africa and

Taiwan.

Côte d’Ivoire: Rebuilding the health system in a post-war context The Côte d’Ivoire health system has improved significantly over past five years and the action plan reflects these priorities. We are very proud of the improvements that have been made – they will leave a legacy - particularly with regards to human resources, which were deflated post-war and weakened the health system. MLIH provided me with the tools to implement the policies which helped effect this change. It also helped identify the core problem of the health system, namely, the different perspectives of the Minister of Health and the Minister of Finance, who thinks only economics and investment. But now we see health as one of the investments. Key improvements include infrastructure (we had a good foundation but had to rebuild this), epidemiology surveillance, and human resources training: (the expertise existed but motivation was key challenge.

Achievement of legacy goals: Taiwan

The former health minister from Taiwan (a participant in the 2014 and 2015 Forums),

accomplished all three legacy goals that he set for himself at the Ministerial Forums. These were:

(a) integrating long-term care into the National Health Insurance scheme through the passage of

Long Term Care Service Act, and increasing the budget for NHI;

(b) passing a stricter food safety law which extended the number of items covered from 30 to 150;

and

(c) improving the quality of care in the remote areas of the Kinmen archipelago which comprises a

number of small islands off the coast of Taiwan. The minister arranged for three medical centers

to send family physicians to these remote health facilities to train health workers and provide

support for complex conditions such as cardiac care. He also made such support a condition for

the future certification of tertiary health centres.

“The MLIH gave good direction to the formulation and achievement of my legacy goals.”

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Kenya – Reform of the pharmaceutical supply chain

When the Kenya Minister of Medical Services came into

office in 2008 he saw the clear need to reform and

streamline the supply of pharmaceuticals and non-

pharmaceuticals. Following his participation in the MLIH

program in 2012, he took advantage of the chaos in the

board of the state-owned procurement group, replaced

the board and gave it 90 days in which to draft a new

law. Although he encountered resistance from the

pharmaceutical cartels, he was able to turn the state-

owned procurement group into an autonomous entity

known as the Kenya Medical supplies Agency (KEMSA)

and reduced price influencing and corruption. This

made government the most cost-effective purchaser

and efficient distributor of pharmaceuticals and non-

pharmaceuticals to local levels.

“I took advantage of this moment of uncertainty to

implement change in government, which minimized

their [industry lobbyists’] efforts to block the

comprehensive reform.”

Mozambique – Rebuilding confidence in the

public health system

In 2012 Mozambique experienced a massive

loss of confidence in the public health system

– both among the public and the donor

community on whom the government was

dependent for public health funding.

The health minister’s participation in the

2012 MLIH Forum prompted him to initiate

two new developments: (a) the introduction

of greater community participation and

community management of drugs at the

district level; and (b) expanding the 5-year

National Health Strategic Planning

consultation to include government, donors,

NGOs, and community representatives, which

enabled him to forge alignment between

these stakeholders and the health ministry’s

priorities.

By working with the finance minister, this

health minister was able to introduce new

vaccines during his term of office, as well as a

number of prevention interventions.

Increased momentum for implementing Universal Health Coverage

Health ministers from five countries attributed their efforts to extend Universal Health Coverage to the

emphasis placed on UHC by the MLIH program.

Philippines: The MLIH program helped me navigate the development of a pro-poor National Health

Insurance program in a very complex environment in which public health was decentralized to district

and provincial facilities through which 40 million people access health services, and to rural centers

which provide primary health care.

Ghana: The MLIH program was influential in my review of the legislation on Universal Health

Coverage and led to the more effective use of funds.

South Africa: I was able to produce the White Paper on Universal Health Coverage in South Africa

using the Harvard perspective.

Taiwan: By working with the Prime Minister and the President, the Second Generation National

Health Insurance Reform turned a deficit into an $8 billion positive balance.

Kenya: I initiated the Social Health Insurance Scheme and partnered with the International Finance

Corporation (IFC) and the Rockefeller Foundation. This helped combat opposition from within

government because the IFC was seen as an outside neutral body and their endorsement of the

reforms was seen as legitimate. We carried out pilot projects, leading to a robust rolling out after I

left the Ministry.

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5.2 Organizing for policy implementation When asked how their participation in the Harvard Program impacted on their role as health

minister, survey participants mentioned the practical skills and tools used to organize their ministries

and manage the implementation of their priority goals the health ministers had set for their

countries (see Figure 2).

More than half (59%) of the respondents (13 out of

22) said the one of the three greatest benefits of the

MLIH Program was to enable them to ‘better

organize, manage and monitor performance within

the Ministry to ensure implementation of my

priorities in health’.

Four of the 22 respondents (18%) said that one of

the top three benefits derived from attending the

MLIH Program was their ability to ‘hold officials

accountable for the efficient use of health resources

and health service delivery’.

Four of the 22 respondents (18%) indicated that one

of the three greatest impacts of the MLIH Program

was their increased ability to ‘use data and

monitoring routines to track progress and

outcomes’.

As is shown in the sidebar above, it is interesting that a small number of ministers have managed to

implement accountability practices and evidence-based performance management, since these are

areas that are known to be particularly difficult to improve.

Figure 2 Policy implementation practices attributed to MLIH Program influence:

Percentage of responses (n=22)

Actions taken post-MLIH Forum to develop monitoring routines Barbados: Implementation of a health information system. Ghana: We began to look closely

at performance appraisals of

Directors and at making the

system work by setting realistic,

practical targets.

Georgia: We are taking the first

steps to create project KPIs and a

monitoring unit in the Ministry

(D-Lab).

Kenya: We introduced regular

reviews with ministry officials so

that they own and are included in

change initiatives.

59%

18% 18%

0

2

4

6

8

10

12

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Better organize, manage andmonitor performance within

the Ministry

Use data and monitoringroutines to track progress and

outcomes.

Hold officials accountable forthe efficient use of health

resources and health servicedelivery

Res

po

nd

ents

Three most helpful aspects of MLIH Program in organizing for policy impemention

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During the focus groups and interviews, the health ministers described the different ways in which

they implemented the MLIH approach to improve the effective operation of their ministries. In a

number of countries, these approaches have been sustained beyond the term of office of the

minister who participated in the MLIH Program, or have been used in other contexts (see section

5.4).

Adopting the delivery approach to drive the implementation of priority goals

Malawi: At the time of MLIH, my country had conducted a study to identify the key issues in the

health system, but needed to develop recommendations and next steps. After MLIH, I felt better

equipped to address this challenge with strong teamwork (monthly meetings), a focus on

implementation as opposed to just planning (a key learning from MLIH), and integration with the

Minister of Finance. After MLIH I created a delivery unit using internal human resources, and

emphasized the importance of maintaining the unit to my successor, who has continued with it.

Jamaica: The strong message from Harvard is a serious attempt to give health the attention it deserves and to provide relevant information despite variation in effective implementation strategies across countries. I was given many recommendations at MLIH on how to organize the ministry to become more efficient and effective (e.g. a delivery unit to drive implementation) and presented them to my team to generate the motivation to strengthen health sector (a key element of my legacy). To combat bureaucratic stasis and the team’s resistance to change, I showed them evidence of wastage to try and motivate more efficient and effective implementation.

Burkina Faso: MLIH helped me improve the organization of my ministry and how you can do a lot with a little. Since my term, my successor has continued to implement my plans.

Taiwan: MLIH was influential to development and execution of achievement of my three legacy goals: I developed a mission and vision, focused on culture change, {and used] key tools such as the balanced scorecard.

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5.3 Health financing Some of the ministers indicated that they had made important gains in respect of improving the

financing for public health in their countries (see Figure 3). The results below indicate that for almost

half the respondents (10 out of 22), one of the top three benefits of the MLIH Program was

improved intersectoral collaboration between the health and finance ministries. A smaller number

of ministers were able to increase the financial resources to support their health priorities: A third of

the respondents produced increases in the health budget from government resources, and six were

able to use their health budget more efficiently and to allocate the resources effectively. Five

respondents were able to identify fiscal space in the health budget to support their top priorities, by

working with the finance minister.

As shown in Figure 3,

Ten respondents (45%) indicated that one of the three biggest impacts from the MLIH

Program was that ‘It led to better collaboration between me and the Minister of Finance’.

Seven of the respondents (32%) indicated that their participation in the MLIH Program

enabled them to produce a health budget increase from government resources.

Six respondents (27%) indicated that participation in the MLIH Program enabled them to

‘implement more effective allocation of the health budget and achieve greater efficiency

in health resource utilization’.

The value of teamwork

Myanmar: The [ministerial] team was so strong that to some extent it jeopardized the original plan of the government. The ministry of health was the only civilian ministry and the team was able to develop a long-term and medium-term plan for health before the new government came into power. The new constitution has 15 regional governments with independent health budgets and health plans, and there is a lack of coordination between the sectoral plan and regional plans. [Today] the leader of the team that participated in the MLIH follow-up workshop is the Minister of Health who has been in office for 1 month. [This former health minister is now special advisor to the Minister of Health in Myanmar.]

Côte d’Ivoire: We have to remember that we are in a Minister’s Cabinet – everything is urgent. The fact that the team is fully engaged, even though I cannot provide them with 100% attention, is very satisfying. Their commitment allows me to build a good strategy to improve health indicators for the country. When I returned from Harvard, I sent an official letter to the other ministers to share my learnings and invited them to create this multi-sectoral team. The team is very engaged and works well together because they know each other very well. They are particularly motivated with regard to Harvard meetings and oversight of portal documents by Harvard. My role in the team [which includes health and finance ministry representatives] is to give the light in health. I need to have a good relationship with the team – keep them motivated, orientate them, direct them and share information.

Namibia: After MLIH, I was able to reorganize my colleagues to establish E8 – a strengthening

collaboration initiative for malaria elimination across eight countries in Southern Africa.

Lesotho: I started a delivery team, which helped to identify talent and allocate heath workers more effectively.

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Five respondents (23%) indicated that participation in the MLIH Program resulted in :

‘Together with the Minister of Finance, I identified fiscal space in the health budget in

support of my top priorities in health’.

Figure 3 Health financing outcomes attributed to MLIH Program influence:

Percentage of responses (n=22)

The value of this component of the MLIH Program is evident from the financial gains made in 10

countries through greater cooperation between the health ministers and their finance counterparts.

One of the key success factors is that the health ministers are now able to engage their finance

ministers in discussion about health as an investment rather than an expense with low returns. Table

3 captures these outcomes and shows that:

Health ministers in six countries increased their health budgets substantially: Cape Verde

secured a budget increase by the health minister showing reduced wastage of 30- 40%; four

countries achieved health budget increases of 2% (Côte d’Ivoire), 18% (Jamaica), 41% (for

malaria elimination in Namibia), and 900% (Myanmar). Taiwan turned a deficit in the NHI

into a positive balance of $8bn and Côte d’Ivoire secured $1m in additional funding for the

continuous professional development of health workers, and for research into local and

regional diseases.

By levying or increasing taxes on tobacco, alcohol and sugar, Barbados, Jamaica and the

Philippines increased health financing by between $8m and $2.5bn.

The Mozambique health minister worked with the finance minister to secure financing to

introduce 3-4 new vaccines and prevention Programs.

Cape Verde and Malawi increased their health financing from donor partners by using the

delivery approach to organize their ministries and demonstrate value for money.

45%

32%

27%

23%

0

2

4

6

8

10

12

Better collaborationwith the Minister of

Finance

The health budgetincreased from

government resources

Used health budgetmore effectively &

efficiently

Identified fiscal space fortop health priorities

Res

po

nd

ents

Three most helpful aspects of MLIH Programthat increased finance for health

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Table 3 Examples of improved health financing in 9 countries participating in the MLIH Program

Country Nature of improved health financing Strategy used to increase financial resources for health

Barbados Increased a tax on sugar sweetened beverages

Collaboration with the Minister of Finance

Cape Verde “Our two major challenges were: 1) attaining the MDGs and 2) 30-40% wastage. To guarantee value for money I had to solve this and put money on the table to get more funds. … The partners increased their resources in the last three years and the delivery method helped secure these funds. It depends on accountability, having clear goals, the rule of law and good governance.”

“I had the opportunity to prove that health was not an expense, but rather an investment. All health ministers have this opportunity after Ebola and other epidemics. … As a mid-income country, it is imperative to improve the efficiency and effectiveness of health spending. Intersectoral arguments can be made to support health investments as a means for economic development. For example, in Cape Verde the elimination of malaria improved tourism.”

Côte d’Ivoire The health budget was at 4% of government expenditure, and is now (2016) at 6%. The health minister is aiming to increase this to 10%. Secured $1 million for continuous professional development for human resources in health, and for research into diseases that are under-researched in the country and the West African region.

On her return from the MLIH Forum, she officially informed the Minister of Budget1 and the Minister of Finance about her learnings and invited them to participate in the multi-sectoral ministerial leadership team. Engaging with the Budget Minister in an annual conference led him to allocate an additional $1 million to human resource development and research.

Jamaica In 2015, post MLIH, the health minister was able to obtain the largest budget increase of 18%. He was also instrumental in working with the finance minister to increase tobacco taxes, which produced an additional JMD1 billion in revenue (= USD8m at 2016 rates).

On four or five occasions he met with the finance minister and learnt how to negotiate with him. “The first meeting was not the warmest”. Fortunately the finance minister was a former health minister and understood the challenges and value of health from a development perspective. The finance minister was ultimately persuaded to increase tobacco taxes on the basis of evidence produced by a health economist. Although the tax increase was less than the health minister had envisaged, it produced an additional JMD1bn in revenue (USD8m).

Malawi Following MLIH, the health minister collaborated with the donor group Joint Health Partners who increased their funding contribution. This was matched by government.

She improved her relationship with the Minister of Finance and strengthened her interaction with donor partners.

1 Côte d’Ivoire has both a Finance Minister and a Budget Minister. The Budget Minister is responsible for resource allocation.

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Country Nature of improved health financing Strategy used to increase financial resources for health

Mozambique The health minister introduced 3-4 new vaccines during his term, launchd prevention interventions and improved ambulance services.

After MLIH, the health minister changed the way he spoke to the Minister of Finance. He hired economists to translate health issues into monetary terms, and the finance minister gained greater sensitivity to health. In the process the finance minister became more open to increasing budgetary allocations for vaccination campaigns, ambulances and other initiatives.

Myanmar The health minister was able to increase public funding for health by 800-900% from $74 million in 2011 to more than $600 million. In addition, the decentralization of actual spending to state and local government increased health service access to the poor, marginalized, vulnerable and high risk populations. “The effective use of budget is contingent on effective capacity to support budgetary allocations/decisions. For example, allocating funds to programs reliant on health workers are limited by health worker capacity.”

Better collaboration with other Cabinet members through the national Health Committee and other stakeholders (CSO, NGOs, UN agencies, bi-laterals, multilaterals) through the Health Sector Coordination Committee.

Namibia The starting domestic budget for malaria elimination was 20%. By the time he left office it was 61%.

“I had been able to convince the President to appoint the Finance Minister to act as Minister of Health whenever I would go outside Namibia on official business. As a result, the [health] budget increased.”

Philippines The passage of the “Sin Tax” (tobacco tax) increased health financing by at least $2.5bn in 2015.

As suggested by the MLIH Program, the health minister moved the debate away from raising money and focused on the value for health. In the context of Catholicism, he also changed the discourse on reproductive health from family planning and abortion to how to protect women from the dangers of pregnancy.

Taiwan The Second Generation National Health Insurance Reform turned a deficit into an $8bn positive balance.

Takeaways from MLIH were to meet with the Prime Minister more frequently and to improve his relationship with Minister of Finance.

Despite these achievements, the former health minister from Kenya points out that “Health financing is still very challenging (controversial) and there is a lingering political belief that health is a private concern.”

Intersection between delivery and increased health financing: Cape Verde After MLIH, I better understood deliverology as being particularly regarding the improved management of existing funds i.e. reduce wasting and redundancies to encourage investment in effective programs. Then I made an argument for greater fund allocation to health efficiency, more than ever because of limited international funding to support different programs. [This way] I managed to attain all MDG goals, including the most difficult (under 5 mortality). and even exceeded some [by] strengthening primary care. The [follow-up MLIH] Program that they implemented to achieve these goals was developed by my “D-Team” (three health ministry and three finance ministry personnel) who attended the South Africa workshop and then conducted in-country training for other personnel. This was a critical step beyond planning. I developed the “D-Team”, which continues to exist and operate even with new Minister of Health.

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5.4 Transferability and continuity of skills One of the features of the context in which the MLIH Program operates is that ministers have a finite

term of office which may or may not extend beyond a five-year period. How relevant are the skills

and approaches advocated by the MLIH Program in contexts other than health ministries? What are

the prospects for continuity?

The data provide a variety of ways in which participants in the MLIH ministerial forums have

continued to use their leadership and other skills in contexts outside the health sector.

Using ministerial skills in different sectors

The essence of skills and knowledge gleaned from MLIH are still relevant to all other sectors, both in government and private sector. I have applied them in the Ministry of Home Affairs and the Ministry of Children, Disability and Social Welfare. Further evidence of the sustainability of the Program is my presence at this meeting and the allowance for me to attend by my President, despite my current role being outside of the health sector. I think a generic MLIH Program for all ministers would be useful to encourage support for Minister of Health. Former Minister of Health, and current Minister of Gender, Children, Disability and Social Welfare, Malawi

Transferability in government

The potential for the continued application of the MLIH approach across changes in government is

illustrated by examples provided by former health ministers from Myanmar, Jamaica, Kenya and

Namibia:

The new Minister of Health in Myanmar (appointed in 2016) was the leader of the

ministerial team that participated in the MLIH follow up workshop in South Africa in 2014.

He has thus worked closely with the MLIH Program and is well versed with using its

approach in a complex environment. Furthermore, his predecessor (a participant in the

MLIH Forum), is now his senior advisor, which provides further room for continuing the use

of MLIH approaches.

An example from Jamaica demonstrates how the health portfolio is closely connected with other sectors, creating opportunities to transfer the skills and orientation acquired through participating in the MLIH ministerial forums:

Even as Minister of Health, I was always aware that health is a portfolio that is intertwined with other sectors. For example, Jamaica’s HIV work policy was developed by Ministry of Health in collaboration with Ministry of Labor and Social Security during my term; and shortly before leaving office, I was also about to pass an Occupational Safety & Health bill.

I am now serving as key spokesperson for Labor and Social Security for the opposition party, but I still maintain an ongoing interest in the health sector because of its impact on entire population. It also has the potential [to function] as a development driver in relation to labor (e.g. absenteeism) and development inhibitor (e.g. catastrophic levels of health expenditure). Former Minister of Health, Jamaica

An example from Kenya also demonstrates how the transformative leadership skills advocated by the MLIH Program can be applied in contexts outside the health sector:

The transferability of MLIH skills and knowledge is great. Even though everyone is no longer a Minister of Health, many are still influential in health policy. For example, I am currently a senator. The senate takes care of devolved systems of government

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(which is currently chaotic) and oversees the health budget allocation at the county level. I am in the finance committee and I chair the Public Finance Committee, so I am able to lead health financing strategies. Former Minister of Health, Kenya

In Namibia the former health minister spoke to his successor and advised him to take part in the MLIH Program, which he is doing. His advice to other governments is to immediately send newly appointed Ministers of Health to the MLIH Program.

Applicability outside government In other cases, former health ministers from Mozambique and Taiwan have used the skills developed through the MLIH Program in private sector engagement and in public education to:

enhance the participation of private sector in public health;

sensitize students of public health to the need for community involvement and the importance of using available resources more effectively and efficiently;

draw on the concepts of leadership, health financing, quality improvement and the use of the

balance scorecard to improve the quality of care in private health care.

Conclusion The 22 health ministers who completed the survey indicated that the three aspects of the MLIH

Program that made the most impact on them were (a) transformative leadership (15 out of 22); (b)

organizing their ministries for the implementation of their health priorities (13 out of 22); and (c)

health financing (10 out of 22). This suggests that over the years (2012 – 2015) all three pillars of the

Program have had positive effects for these participants.

In focus groups and interviews, 14 ministers attributed a number of tangible health reform

outcomes directly to the influence of the MLIH Program. For example, the Program seems to have

substantial impact on ability of five countries to make progress towards Universal Health Coverage

(Ghana, Kenya, Philippines, South Africa and Taiwan). Other systemic changes in health include

rebuilding the health system in post-conflict Côte d’Ivoire, reforming the pharmaceutical supply

chain in Kenya, rebuilding confidence in the Mozambique public health system, achieving all the

MDGs in Cape Verde, passing a stricter and more extended food safety law in Taiwan and improving

the quality of care in its remote areas.

The ministers’ accounts cite as a critical success factor their ability to better organize their ministries,

and improve their management and monitoring of performance. Significantly, increased fiscal

support for health reform was achieved in 10 countries by closer cooperation between the health

ministers and their finance ministers. This included reallocating the health budget more effectively,

and using health resources more efficiently.

Despite these positive results, the data suggest that more work is required to achieve similar health

financing gains in a larger number of countries. Similarly, the MLIH Program needs to find ways of

assisting more health ministers to practice evidence-based decision-making, and to strengthen

accountability levels among their officials for effective health service delivery.

Finally, the data suggest that the skills and approaches advocated by the MLIH Program are

transferable to contexts beyond the health sector. The ministers recounted how they have used

their MLIH experience in other government departments, in other capacities in government, and

outside government in private health care and in training students of public health.

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