The path to universal The path to universal coverage coverage : : The World Health Report The World Health Report 2010 2010 11 October, Nossal Institute, Melbourne 11 October, Nossal Institute, Melbourne Martina Pellny, Technical Officer Health Care Financing, Martina Pellny, Technical Officer Health Care Financing, WHO Regional Office for the Western Pacific (WPRO), WHO Regional Office for the Western Pacific (WPRO), 4 th Technical Review Meeting for the Health Policy and Health Finance Knowledge Hub
Transcript
The path to universal coverageThe path to universal coverage::The World Health Report 2010The World Health Report 2010
11 October, Nossal Institute, Melbourne11 October, Nossal Institute, Melbourne
Martina Pellny, Technical Officer Health Care Financing, Martina Pellny, Technical Officer Health Care Financing, WHO Regional Office for the Western Pacific (WPRO), WHO Regional Office for the Western Pacific (WPRO),
DPS, FijiDPS, Fiji
4th Technical Review Meeting for the Health Policy and Health Finance
Knowledge Hub
2 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
WHR topic based on World Health Assembly Resolution in 2005The Resolution 58.33 defined “Universal Coverage” asThe Resolution 58.33 defined “Universal Coverage” as coverage coverage
with: with: needed health services; financial risk protection; for needed health services; financial risk protection; for everyone.everyone.
The aspiration to attain universal coverage is not new. You find reference to it in: WHO's constitution-1948; Alma-Ata Declaration-1978; World Health Report on Primary Health Care-2008 etc
The resolution also states that universal (health) coverage can not be achieved without a well-functioning health financing system
3 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Three Dimensions
1.
2.3.
4 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Millions suffer financial ruin when they use health services:Millions suffer financial ruin when they use health services:
Globally around 150 million suffer severe financial Globally around 150 million suffer severe financial hardship/ catastrophic health expenditures each year.hardship/ catastrophic health expenditures each year.
100 million are pushed into poverty because they must 100 million are pushed into poverty because they must pay out-of-pocket at the time they receive health pay out-of-pocket at the time they receive health services. services.
5 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
- 30 60 90
WPR
AMR
SEA
EUR
AFR
EMR
Number of people (million)
impoverishment
catastrophic
Highest burden in Asia: In the WHO WPRO region 80 million people experience financial catastrophe and 50 million impoverish due to health payments (half the people worldwide). Source: Equitap
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35 PNG32 LAO
14 PNG
33 LAO
18 LAO
56 LAO
42 VTN
17 VTN
30 LAO
20 LAO
95 VTN
83 VTN83 VTN
87 VTN
76 PHL
80 VTN82 CAM/ MOG
79 MOG81 MOG
99 MOG
0
20
40
60
80
100
SBA Early BF EBF BF & CF NT Vit A Measles ORT ARI ITN
Perc
enta
ge
Source: CHIPS 2009
2. Dimension: which services are covered?2. Dimension: which services are covered?2. Dimension: which services are covered?2. Dimension: which services are covered?
8 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
3.Dimension: who is covered?3.Dimension: who is covered?PPercentage of births attended by skilled health workerercentage of births attended by skilled health worker
3.Dimension: who is covered?3.Dimension: who is covered?PPercentage of births attended by skilled health workerercentage of births attended by skilled health worker
02
04
06
08
01
00
0 10 20 30 40 50
Q1Q5 Average
Source: Latest available DHS for each country (excl. CIS countries)
Q1, Q5 and Average - 22
countries
9 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
The WHR-2010 proposes three inter-related health financing strategic options for universal coverage:
- Raise sufficient funds for health: More money for health
- Reduce heavy reliance on direct OOP: More equity for health.
- Reduce and eliminate inefficient use of resources: More health for the money
Proposing solutions: the WHR 2010Proposing solutions: the WHR 2010Proposing solutions: the WHR 2010Proposing solutions: the WHR 2010
10 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Problem 1: Problem 1: Insufficient fundsInsufficient fundsProblem 1: Problem 1: Insufficient fundsInsufficient funds
A set of essential health services focusing on the Millennium A set of essential health services focusing on the Millennium Development Goals would cost on average US$ 44 per capita in Development Goals would cost on average US$ 44 per capita in low-income countries in 2009, rising to US$ 60 in 2015 low-income countries in 2009, rising to US$ 60 in 2015 (estimates provided by the HLTF on Innovative International (estimates provided by the HLTF on Innovative International Financing for Health Systems).Financing for Health Systems).
31 low income countries spent less than US$ 35 per person 31 low income countries spent less than US$ 35 per person (2008) (2008)
Only 8 have any chance of reaching the required funding from Only 8 have any chance of reaching the required funding from domestic sources by 2015 - even assuming rapid growth of their domestic sources by 2015 - even assuming rapid growth of their domestic economies. domestic economies.
11 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Options for raising more domestic funds for healthOptions for raising more domestic funds for healthOptions for raising more domestic funds for healthOptions for raising more domestic funds for health
Increase the priority given to health in government budget Increase the priority given to health in government budget allocationsallocations
MoHs often not powerful enough – loose out in budget negotiations MoHs often not powerful enough – loose out in budget negotiations Ex: MTEF - clear and transparent targetsEx: MTEF - clear and transparent targets Ex: Abuja declaration: African heads of state declared in 2001 to Ex: Abuja declaration: African heads of state declared in 2001 to
increase the share of government expenditures going to health to increase the share of government expenditures going to health to 15% of GGE in 2007, and failed15% of GGE in 2007, and failed
Raise revenue for health more efficiently – e.g. increase the Raise revenue for health more efficiently – e.g. increase the total availability of resources (strong tax base)total availability of resources (strong tax base)
In Indonesia, clear and consistent regulations and a policy of zero-In Indonesia, clear and consistent regulations and a policy of zero-tolerance for corruption increased tax yield from 9.9% to 11% of GDP tolerance for corruption increased tax yield from 9.9% to 11% of GDP over four years – with a subsequent increase in health expenditures. over four years – with a subsequent increase in health expenditures.
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Find new sources of domestic funds e.g.Find new sources of domestic funds e.g.
"Sin" taxes on tobacco and alcohol: a 50% increase in tobacco tax alone would yield an additional US$ 1.42 billion - this could increase government health expenditure by up to 25%.
Excise tax on unhealthy food – Romania – 20% on foods high in fat, salt, sugar
Levy on currency transactions would be feasible in countries with large markets – e.g. India could raise US$ 370 million per year from a very small levy (0.005%).
Levy on remittance transactions - GabonLevy on large/ profitable companies – Australia (mining companies);
Options for raising more domestic funds for healthOptions for raising more domestic funds for healthOptions for raising more domestic funds for healthOptions for raising more domestic funds for health
13 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
The WHR-2010 proposes three inter-related health financing strategic options for universal coverage:
- Raise sufficient funds for health: More money for health
- Reduce heavy reliance on direct OOP: More equity for health.
- Reduce and eliminate inefficient use of resources: More health for the money
Problem 2:Problem 2: Heavy reliance on direct OOPsHeavy reliance on direct OOPsProblem 2:Problem 2: Heavy reliance on direct OOPsHeavy reliance on direct OOPs
14 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Options to reduce the impact of OOPsOptions to reduce the impact of OOPsOptions to reduce the impact of OOPsOptions to reduce the impact of OOPs
Reducing OOPs requires switching to systems of “prepayment” with subsequent “pooling” of revenues (Prepayment means paying before illness – and it can take the form of taxation or insurance – Beveridge/ Bismarck/ mix). PREPAYMENT
There seems a minimum level of compulsory prepaid funding that is necessary to ensure that the poor and vulnerable are covered: ca. 4-6% of GDP. See WHO WPRO benchmark: “Universal coverage is difficult to achieve if public financing is less than 5% of GDP”. MINIMUM
Community and micro-insurance can play a useful role in the early stages, but plans to merge them over time are important - bigger pools are more financially viable than small community-based pooled funds. CONSOLIDATE POOLS AND REGULATE
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Options to reduce the impact of OOPsOptions to reduce the impact of OOPsOptions to reduce the impact of OOPsOptions to reduce the impact of OOPs
Options in addition to prepaid and pooled resources to ensureOptions in addition to prepaid and pooled resources to ensuregreater coverage and lower financial barriers:greater coverage and lower financial barriers:
Free or subsidized services (e.g. through exemptions or vouchers) for specific groups of people (i.e. the poor) or for specific health conditions (i.e. child or maternal care).
Subsidized or free insurance contributions for the poor and vulnerable.
Cash payments to cover for ex. transport costs for the poor.
16 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Problem 3:Problem 3: Inefficiencies Inefficiencies Ten leading source of inefficiency Ten leading source of inefficiency
Problem 3:Problem 3: Inefficiencies Inefficiencies Ten leading source of inefficiency Ten leading source of inefficiency
1. Medicine: underuse of generics and higher than necessary price.
2. Medicine: use of substandard and counterfeit medicines.
3. Medicine: inappropriate and ineffective use.
4. Products and services: overuse/supply of equipment, diagnostic services and procedures.
5. Health workers: inappropriate or costly staff mix, unmotivated workers.
6. Health service: inappropriate hospital admission and length of stay.
7. Health service: inappropriate hospital size and low use of infrastructure.
8. Health service: medical errors and suboptimal quality.
9. Health system leakages: waste, corruption and fraud
10. Health intervention: inefficient mix and inappropriate level.
17 |Health Systems Financing and the Path to Universal CoverageThe World Health Report 2010
Options to encourage greater efficiencyOptions to encourage greater efficiencyOptions to encourage greater efficiencyOptions to encourage greater efficiency
For example: For example:
1.1. Paying providersPaying providers:: move away from fee for service if possible. Consider move away from fee for service if possible. Consider results-based payment where good monitoring is possible etc. results-based payment where good monitoring is possible etc.
2.2. Medicines:Medicines: improve prescribing guidance, training of staff; incentives improve prescribing guidance, training of staff; incentives for generic substitution; regulate promotional activities, more public for generic substitution; regulate promotional activities, more public information (irrational use) etc.information (irrational use) etc.
3.3. Health services/ governance:Health services/ governance: Provide more continuity of care, Provide more continuity of care, monitor hospital performance, improve regulatory capacitymonitor hospital performance, improve regulatory capacity
4.4. Reduce duplicationReduce duplication – avoid “fragmentation” with - Funding channels; - – avoid “fragmentation” with - Funding channels; - Laboratory systems; - Auditing and monitoring systems; - Reporting Laboratory systems; - Auditing and monitoring systems; - Reporting systems including reporting to donors (Aid effectiveness principles).systems including reporting to donors (Aid effectiveness principles).
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Greater efficiency includes Greater efficiency includes comprehensive health planscomprehensive health plans
National health plans
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ConclusionConclusionConclusionConclusion
Regardless of the stages of development, each country can improve their financing systems to maintain or progress towards universal coverage.
The global community can do more to raise needed funds and strengthen national financing institutions and capacities to attain universal coverage.
Stop introducing more global initiatives with more secretariats at Stop introducing more global initiatives with more secretariats at the international level.the international level.
Buy into the countries national health plans and channel funds Buy into the countries national health plans and channel funds to countries in ways that build domestic financing capacities and to countries in ways that build domestic financing capacities and institutions, rather than bypassing weak systems – e.g. fund institutions, rather than bypassing weak systems – e.g. fund Sector Wide Approaches, General Budget Support etcSector Wide Approaches, General Budget Support etc
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