Universal Coverage Making Health Systems Financing a Priority by sammyc2007

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									Universal coverage: making health systems financing a priority in global health
by

Timothy Evans Assistant Director-General World Health Organization
Crossroads in International Health, Toronto, 20-21 April 2006

Better Financing for Better Health

Evidence and Information for Policy (EIP)

Contents

I. II. III. IV. V.

Health financing in the world Health financing for universal coverage Current challenges in selected countries Current challenges across countries Conclusion

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I.

Health financing in the world

•
…

A great deal is spent globally but unevenly distributed and high reliance on out-of-pocket payments in many countries

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High income countries with less than fifth of world population consume three-quarters of health resources
Inequality in health spending and income by WHO Region*, 2003
measured in International dollars
Population

80 70 60 50
%

GDP Health expenditure

40 30 20 10 0
AFR AMR* EMR EUR* SEAR WPR* OECD
* A M R , EU R and W PR d o no t co nt ain OEC D co unt r ies Source: National Health Accounts, EIP/HSF/CEP, World Health Organization

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In 2003, the World spent $4.4 trillion on health (International dollars)

OtherPrivate 4%

Social Insurance 24%

Tax funded 32%

Private Insurance 17%

Out of pocket 23%
So urce: Natio nal Health A cco unts, EIP /HSF/CEP , Wo rld Health Organizatio n

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Better Financing for Better Health

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Number of People with Catastrophic Expenditure and Impoverishment Due to Health Spending
EMR AFR EUR SEA AMR WPR

impoverishment catastrophic

-

30

60

90

Number of people (million)
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• Policy concern about out-of-pocket spending It can: – Result in catastrophic health spending ( > 40% of income net of subsistence needs) – impoverish people – prevent people from seeking or obtaining needed health care

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II. Health financing for universal coverage

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What is universal coverage?
• Universal coverage (UC) means coverage with needed health services (personal and non-personal) for all people and at an affordable cost … This is often called Equity in access
-

with access interpreted as securing services to everyone, given need
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• UC is also associated with Equity in financing implying that households contribute on the basis of ability to pay

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How to achieve universal coverage?
• Organisational mechanisms are needed to:
– Collect financial contributions equitably and efficiently – Pool these contributions so that the financial risks associated with the need to pay for care are shared by all – Purchase or provide effective and cost-effective health interventions with these contributions

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• 'Broad' organisational options:
– Tax-based health financing (TBF)
– Social health insurance (SHI)

– Mixed health financing systems (MHF)
• With part of the population covered by tax revenues or various types of health insurance • Some groups covered by both

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• Historical and social choices determine which type of system forms the basis, but the important characteristics are that:

– A high proportion of household financial contributions are prepaid and pooled

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The transition to universal coverage

• In countries that have achieved or are close to achieving universal coverage, the transition generally took some years. • During the transition, co-existence of
– Community-, cooperative-, enterprise-based health insurance – Other forms of private health insurance – Compulsory SHI-type coverage for particular population groups – Tax-based funding
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Stages of coverage and organisational mechanisms
Universal Coverage * Tax -based financing * Social health insurance

* Mix of tax - based financing and various types of health insurance Intermediate stages of coverage
* Mixes of community Cooperative-and enterprise-based health insurance, other private health insurance, SHI-type Absence of financial protection * Out-of-pocket spending for health care coverage for specific groups and tax-based financing

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The speed of transition
• Examples
– Both Japan and UK took 36 years between 1st law related to UC and the final law to implement it – However, Thailand took about a year to implement coverage for Thais not yet covered by SHI (although many years of laying the basis for this)

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III.

CURRENT CHALLENGES IN SELECTED COUNTRIES

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Transition to UC expanding health insurance
Viet Nam

• Decree of 1992 on health insurance

• More recent laws to expand health insurance to the rural sector and the poor

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Transition to UC with official recognition of mutual health funds

Senegal

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Zambia
• Scale and Squeeze Finacing!
• $9/capita gov spending on health • $9/capita donor pool to gov for health
– Budget support, SWAp

• $18/capita external donor support to nongovernmental health actors

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Source: Ministry of Health, Zambia, in collaboration with WHO. Map production: Public Health Mapping and GIS/WHO.

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IV.

CURRENT CHALLENGES ACROSS COUNTRIES

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Cross-country challenges
• Health Systems Financing for Universal Coverage
• A political priority?
– National or Global

• A roadworthy strategy?
– coverage of population groups ? – contributors and beneficiaries? – revenues and their allocation ?

• A cost-effective investment? • Capacity for UC?
– Skilled workforce? – Strong institutions?- legal, financial

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Real costs of scaling-up?
• Systematic costing underestimation related to "hardware of health systems" such as workforce, labs, facilities etc
• • • • TB interventions – 46% HIV treatment – 35% Malaria – 24% Maternal and neonatal health – 18%

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Cross-country challenges
• Fiscal "space" and "sustainability" • MDGs and universal coverage?
• Universal coverage for HIV/AIDS? • Sustainable financing for TB?

• Global funds – friend or foe? • Donor "predictability" • Global instruments at country level
• budget support, MTEF, PRS, SWAPs
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Unravelling the global health systems genome
• MDGSWAPMTEFPRSP PEPFARCCMRBMICC GFATMSTOP! • RBMMVIMMVIPTIMA CEDO…
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V. Conclusions
• Global actors to work together to support national health systems financing strategies - now and in the long-term

• Must articulate the investment package for building health financing systems financing packages. • More comprehensive understanding of the true costs of developing health systems • Metrics to monitor the "health" of health financing systems
• Need for a "Health Systems Financing Priority Project" • Can we move from DCP2 to HSFPP1?

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