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

9

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)

10

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

Courtesy of World Bank Photo Collective

12

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

12

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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