1. Strengthening health financing governance - Estonia country experience
Andres Rannamäe

2. Background information
Estonia – country in North-East Europe, member of EU
1,32 M inhabitants
GDP – USD per capita (estimate 2017)
Good health at low cost - Health outcomes close to EU-15 average, health expenditure lowest among EU-15 (WB)
National health insurance coverage >96%
13% earmarked payroll tax payed by employer
Principle of solidarity
From 2018 Government extra contribution for pensioners

3. Phase 1 - Health financing governance 1991-2001
National health insurance since 1991, establishment of NHIF with semi-independent district branches (17) and Board of Directors
Main concerns
Fragmentation - of the organization, pooling of funds, purchasing arrangements, management and governance
Low capacity – of the NHIF management and performance (key functions, HR & IT), low capacity of governance and governors
No strategic coherence and direction

4. Phase II - Health financing governance beyond 2001
consolidation of NHIF into one legal entity (HQ + 4 regional branches), single pooling and single payer organization
Executive Board up to 4 members, NHIF managed by own law
Unified Board of Directors on national level only, 15 members
5 from Government and Parliament
5 from Employer Association
5 from user associations – pensioners, children, patients, trade unions
Audit Committee
Clear governance arrangements and accountability

5. Phase 1 - Health care provider sector 1991-2001
100+ hospitals attached to the MOSA
Governance of hospital performance very formal by MOSA
PHC and family medicine reform 1994, independent practices with average headcount of people per family doctor
Main concerns
Over capacity of hospital network
Out-dated medical technology and facilities
Health financing methods not motivating efficiency and quality
Old mental paradigms, including ownership and accountability

6. Phase II - Health care reform 2001 and beyond
Hospital Master Plan – from 100+ hospitals down to 18 acute care hospitals
The rest are for palliative and nursing care, closed down or merged
Full autonomy of service providers, hospitals have own governing body and arrangements
Hospitals managed according to private company law, yet most of them are “non-profitable”
Challenges
Provider discontinuity and integration of care
Strengthening primary and out-patient care

7. The organization of health financing and NHIF governance
Government
Board of Directors
Executive Board

8. Strengthening health financing governance – system approach
New law of NHIF from 2001 defines legitimate role and responsibilities of the BoD
Defining strategic direction and approving key decision
Overseeing executive board and NHIF performance
Building governors and Board capacity
Building transparent and evidence based reporting
Strengthening public accountability

9. The governance “good practice”
BoD is disciplined and committed, governance works
Board engagement in core issues
Health needs? HBP?
Provider related issues? Strategic purchasing?
Health financing mechanisms & issues?
Quality of reporting is a key to good governance, governing body to set high standards for reporting
Evidence based reporting, shift from “what was done towards what was achieved”
Interdependency of the qualities of executive and governing bodies

10. The “governance issues”
Government definition of “owner” mandate vague
Difficulty to resolve by governors a clear and shared sense of the distinctive purpose of the purchaser – the value delivery
Clarity of setting strategic direction
Political power overdrives the professional competency 
Rotation of governors rather high, an issue of sustainability
Board leadership is a challenge, defensiveness in attitude, little drive for change
“Building and pushing the governance bottom-up”!?

11. Increasing the capacity of the governing body
Commitment and leadership in setting strategic direction and keeping organization on selected track
Focus on strategy creation & execution
Create a need/demand for strategic discussion – relevant reports and inputs provided by executive board to “push” the discussion, diversity of ideas
Aligned and engaged around the strategy
More strategic

12. Increasing the capacity of the governing body
Organization & Competency
Does size matter?
Good mix of professional competencies
Board leadership and stronger interaction between non-executive and executive boards
Build common knowledge base with BoD – joint seminars and events, brainstorming, learning from experience
Understand value delivered, impact made and assure “evidence based” meaningful reporting
Capacities & Learning

13. Increasing the capacity of the governing body
Understanding key stakeholders, build relations
Openness, transparency, accountability – create corresponding environment, communication channels, public relations
Stakeholder relations

14. The capacity of oversight bodies … change in governance concept
Dynamics in governance roles – from control and “no trust” towards stewardship and leadership
Balancing monitoring and mentoring
Overcoming the gap between executive and governing boards, more personal interaction between the boards
Diversity of thoughts, open discussion
Public sector need better governance to support efficiency and value delivery

15. Challenge of strengthening the health financing governance in Sudan
New Health Policy challenge to design entire health sector governance framework to support achieving UHC and implementing health finance strategy and health service delivery
Great opportunity – NHIF in transition, strengthening of the health financing governance clearly in the agenda
Assessment of NHIF governance done by WHO late 2016
Donor support and technical assistance available

16. Thank you for your attention!