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3 August 2004
Public Health Practice III: FINANCING PUBLIC
HEALTH REFORM
Thomas E. Novotny MD MPHUniversity of California San Francisco
Institute for Global Health
Learning objectives Establish context for health systems
Provide general description of existing healthcare systems
Describe role of World Bank in policy
Present current World Bank policy
Identify issues with proposed direction
Populations and disease
Health status indicators
Epidemiologic transition
Demographic transition
Poverty as root cause
Declaration of Alma Ata (1978) Definition of health
State of complete physical, mental and social wellbeing
Not merely absence of infirmity or disease Fundamentally human right Attainment of highest possible level is
worldwide priority and common concern of all countries
Primary care Essential health care Universally accessible Affordable cost
Primary health care defined Addresses main health problems in
community Provides promotive, preventive, curative
and rehabilitative services Broad definition to include proper
nutrition, safe water, basic sanitation, prevention and control of communicable diseases, provision of essential drugs
Promotes community self-reliance using local and national resources
Elements of Health Systems Production of resources (people,
supplies, facilities, knowledge) Organization of programs (government,
private providers, NGOs) Economic support mechanisms (source
of funds) Management methods (planning,
administration, monitoring and evaluation) Delivery of services
(preventive/curative, primary/secondary/tertiary, public health)
Economic Dimensions of Health Systems
Source of payment Voluntary (private insurance, user fees) Compulsory (taxes, social insurance)
How services provided Direct ownership by government Contractual arrangements Private providers paid directly by consumer
How services paid Prospectively – provider assumes risk Retrospectively – costs reimbursed
Four key actors
Government
Population to be served
Financing agents
Providers
Four key functions
Regulation
Financing
Resource allocation
Providing services
Current situation Government as largest provider
universal access high spending on hospitals highly centralized bureaucratic fluctuating budgets poor motivation
ISSUES
Market model not panacea
Ability of Ministry of Health to lead transformation
Lack of management capacity to implement changes
Current situation
Changing public or private insurance
Half of spending “out-of-pocket” Mainly pharmaceuticals
Current situation
Limited power of Ministry of Health
Private provider = quality provider
Lack of access for certain populations
World Bank as opinion leader
Health is addressed through economic development
Burden of disease translates into economic terms (DALYs)
World Bank as opinion leader
Government and private sector have
separate roles
prevention/public health
essential package of services
curative care
World Bank as opinion leader
Health system barriers to progress misallocation inequity inefficiency exploding costs
Why health sector reform?
Recognition of need for healthy population
Part of overall lending packages
Enhancing the performance of health services
Key concepts for health sector reform
Accessibility
Efficiency
Effectiveness
Quality
Consumer satisfaction
Accessibility
Equitable
Reduced barriers
Effectiveness
Spend money in the right place – most benefit to most people
Improve clinical outcomes
Increase accountability
Efficiency
Maximize the money spent
Increase management capacity
Provide incentives
Quality
Incentives for change
Information widely available
Accreditation processes
Consumer satisfaction
Increased choice
Informed choice
Input to services provided
POLICY SOLUTIONS
Enable households to improve health
Improve government investments in health
Promote diversity and competition in financing and delivery
POLICY ONE: Enable households
Economic growth policies that benefit poor
Expand investment in schooling Promote human rights
POLICY TWO: Improve government investment
Reduce spending on tertiary and
specialty care with low cost benefit
Finance and implement package of
public health interventions
POLICY TWO: Improve government investment
Finance and ensure delivery of package of essential clinical services
Improve management through decentralization and budget autonomy
POLICY THREE: Promote diversity and competition
Government provides public health and essential services
Private insurance for clinical services outside essential package
POLICY THREE: Promote diversity and competition
Encourage privatization of all clinical
services
Produce information on provider
performance
Expanding access to health research.
www.plosmedicine.org
•Open-access general medical journal from the Public Library of Science
•Peer reviewed, international, broad in scope
•Experienced professional editors, efficient constructive review process, rapid publication
•Original research and interpretation
•In PubMed, freely available online, widely distributed in print
•Submit your best studies and share the results with the world
•Contact: [email protected]