Post on 10-Feb-2017
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The Devil is in the DetailsDesigning and Implementing UHC Policies that Reach the MarginalizedSuneeta Sharma, PhDPrince Mahidol Award Conference, January 29, 2017
Courtesy of Department of Foreign Affairs and Trade
Decisions to increase coverage of
essential health services for all,
especially reaching the
marginalized and poor, need to
cover a variety of domains going
beyond the “cube.”
UHC is not only about health
financing decisions, but a
converging set of health policy
strategies and options.
The devil is in the details.
How did countries approach this,
where are they now, and where
are they heading?
2
Beyond the Cube
• Learning from the Latin America andCaribbean (LAC) experience
• Progress in middle-income Asia
• Applying the lessons in low-income settings
• Summary
3
Outline
The Latin America and CaribbeanExperience
Courtesy of World Bank Photo Collective
5
Where are LAC countries at andwhen did they start?
Year ofcritical UHC
policy
Groups to cover/originalfocus
Chile (FONASA) 1981-Those not covered bycontributory insurance
Costa Rica (CCSS) 1984- Entire population
Brazil (FHS) 1988- Entire population
Colombia(Subsidized Regime)
1993-Those not covered bycontributory insurance
Guatemala (PEC) 1997-2014Rural population, especiallypoor
Peru (SIS) 2002- Entire population
Jamaica (NationalHealth Fund)
2003-Chronic disease and theelderly only
Mexico (SeguroPopular)
2003-Those not covered bycontributory insurance
Argentina (PlanNacer)
2004-Mothers and children notcovered by contributoryinsurance
Uruguay (SNIS +FONASA)
2007- Entire population
Health Insurance Coverage, 2015
Source: World Bank, 2015 and IDB, 2014
Co-existence of high coverage ofinsurance & inequities in LAC
Gaps in reproductive health accessby indigenous or ethnic origin
Gaps in maternal, newborn, and childhealth access by wealth quintile haveclosed over time, but not everywhere
Skilled birth attendance by country, year, and quintile
Proportion of women who accessed skilled birth attendance, by DHS yearSource: Lancet 2015
0%
20%
40%
60%
80%
mCPR among women married or inunion
Total population Indigenous population
mCPR: modern contraceptive prevalence rateSource: DHS or national surveys
What worked in LAC:• Increased share of population covered
by explicit guarantees—46 millionpeople added since 2006
• Heavily subsidized programs havestarted and maintained coverage
• Reduced out-of-pocket spending
• Equalized benefits across groups
Remaining challenges• Some inequities remain—all gaps not
closed for poor or indigenous
• Huge diversity: Guatemala, Haiti, etc.,are much behind
• Covering all services equally is achallenge—partly financial, partlypolicy implementation
Summary: Choices have consequences,which proper design can anticipate
Cost per person,US$ (2011)
As % of per capitaGDP (2011)
Chile(FONASA)
$313 2.2%
Costa Rica(CCSS)
$589 6.8%
Brazil (FHS) $125 1%
Colombia(SubsidizedRegime)
$120 1.7%
Guatemala(PEC: closed)
$7 0.2%
Peru (SIS) $16 0.3%
Jamaica (NationalHealth Fund)
$108 2%
Mexico (SeguroPopular)
$122 1.3%
Argentina (PlanNacer)
$42 0.4%
Median $39 1.4%Source: World Bank, 2015
Progress in Middle-Income Asia:Philippines and Indonesia
Courtesy of Ikhlasul Amal
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Philippines PhilHealthHigh enrollment with a limited benefits packagePhilippines’ path to UHC
Pre-1969 1969 1996
Ministry of Healthcovers everyone for free
Medicare - social securityscheme for formal sector
workers
Philippines HealthInsurance Corporation(PhilHealth) launched
Strengths Challenges
PhilHealth key characteristics as part of the National Health Insurance Program• Contributory and non-contributory (subsidized) mechanisms• Limited benefits package based on priorities: Includes key primary health care services,
e.g., TB-DOTS; maternal, child, and neonatal health
Low protection of the poor from catastrophic healthexpenditures from hospitalizationFinancial sustainability—unstable budget (2016 cost atestimated 75% utilization: $928 million)Membership ≠ access (difficulties enrolling poor)Hospital governance and accountability
Strong legal foundation: NationalHealth Insurance Law (1995)Strong political willSubsidized program for poor (~18%of population)
201581.6 million
beneficiaries, 82% ofthe population
This image cannot currently be displayed.
2010
Agenda on UHC(Kalusugang
Pangkalahatan)
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Indonesia’s JKN schemeGrowing coverage with financial sustainability challenges
Indonesia’s path to UHC
2011 2014 2019Social SecurityAgency formed
Schemes consolidated; singlepayer national scheme: JKN
launched
Current target for universalcoverage (~90%)
Strengths Challenges
JKN: key characteristics• Contributory and non-contributory (subsidized) elements—poor pay nothing out-of-pocket to
access JKN package• Comprehensive benefits package covering all key primary, secondary, and even tertiary care
needs
Financial sustainability—rising healthcare costscausing increasing annual deficits
Cardholding ≠ effective coverage or access—geographical and other inequities present
Initially severe adverse selection—voluntaryinformal sector enrollment was not broad
Strong political commitment and legalbacking
Enrollment coverage increased—172million members in Jan 2017 (66%coverage)
Explicitly subsidizes a large populationof poor and near-poor (97.4 million)
Series of regulatoryacts and decrees
Rapid scale up ofenrollment (‘til 2016)
2004National SocialSecurity System
2012PBI subsidy
started
Applying the Lessons in Low-IncomeSettings
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Convergence in Policies
• Sound legal basis: LAC, Philippines,Indonesia—all enacted legislation
• Enable regulations in place;strengthen or form institutions:PhilHealth, JKN, CCSS, etc.
• Purchasing based on increasingchoice and efficiency
• Mobilize resources to cover the poor(non-contributory)
• Policies for demandgeneration/socialization for remotegeographies and all ethnic groups
• Design benefits package to cover keyhealth needs
• Engage private sector on level ofcontributions, provision
• Engage other stakeholders
Policy Implementation
• Strong role of decentralizedlevels in monitoring and fundingUHC programs
• Monitor access, utilization, andquality
• Ensure stakeholders have a rolein periodic program evaluationand improvement
Hard decisions to anticipate
• Affordability vs.comprehensiveness
• Sustainability of UHC-orientedscheme vs. inclusion ofpopulation groups, equity
• Quality improvements withefficiency
Planning for inclusion of all groups inUHC programs: no one formula
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Thailand’s UHC Journey: TheImportance of Political Will
• Commitment at legislative(constitutional), political(consensus), and financial(budgetary) levels
• Multi-year effort, sustainedover political dispensations
• MOPH leadership + networkof CSOs worked togetherover early 2000s NHAsubmitted to parliament
Evidence base
Socialmovement
Politicalwill
HealthReform
However, there are things to look out for…
Thank you!ขอบคุณ!
Courtesy of World Bank Photo Collective
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