financing health care and economic issues. overview and objectives 7 weeks of gh 511 – where are...
Post on 28-Dec-2015
213 Views
Preview:
TRANSCRIPT
Financing Health Care and Economic
Issues
Overview and Objectives• 7 weeks of GH 511 – Where are we now?• A message on health systems strengthening…• History of health policy, economic policies,
and aid for health• Elements of health care reform• 3 health financing functions with specific focus
on revenue collection• Share your perspectives and experiences
Your Experiences with Health Care Reform and Financing
• What different types are used in the countries where you have been?
• How have they worked?
• Challenges with implementation?
Need MONEY and PEOPLE who know how to LEAD and MANAAGE
Determinants of Global Health
Interests of rich
Status of women
Land tenure
Debt-SAPs
Weak governments
Militarism
Imperialism
Poverty
Disparity
Access to education
Job conditions
Gender issues
Civil strife
Malnutrition
Water
Sanitation
Housing
Health care services
Health behaviors
DiarrheaPneumoniaPerinatal conditionsHIVInjury MalariaMeasles
Underlying Proximate DiseasesIntermediate
Global and national
National and community
Family Individual
Health Care Systems
• Complex systems consisting of:– Health care consumers = people in need of health
care services– Health care providers = people who deliver health
care – Systematic arrangements for delivering health
care = public and private agencies that organize, plan, regulate, finance, coordinate services
Health care can be “catastrophically costly” and need can be unpredictable
Six Building Blocks of a Health System
Source: Strengthening Health Systems to Improve Health Outcomes, WHO’s Framework for Action – WHO 2007
System Inputs Overall Goals/Outcomes
5 Fundamental Questions
1. What are the boundaries of health systems?2. What are health systems for?3. How do we characterize the architecture of a
health system?4. How can we tell when a health system is
performing well?5. How do we relate architecture to health
system performance?
Six Building Blocks of a Health System
Source: Strengthening Health Systems to Improve Health Outcomes, WHO’s Framework for Action – WHO 2007
Purposeful change aimed at improving health system performance for:
System Inputs
What do we mean by health systems that are...
Equitable?• Ability-to-pay determines financing contributions • Use of services is based on need for care
Efficient?• How well a health system achieves the desired health
outcome given available resources
Responsive?• Protects one’s dignity and autonomy
Able to offer social and financial protection?
History of Health Care Reform
1970s: Primary Health Care as Health Care Reform
1980s: Structural Adjustment Programs - reduction of public budgets, global concern about health care
– Bamako Initiative– USAID Health Care Reform initiatives– Privatization
1993: World Bank – Investing in Health
What’s next?
1945 1955 1965 1975 1985 1995 2005
1945 1955 1965 1975 1985 1995 2005
Debt & SAPs
IMF & World Bank
Debt Crisis
Structural Adjustment Programs
Health Policies
Equity Oriented Strategies
PHC and Selective PHC
WB Health Sector Reform(1978) Alma Ata
Chronology of Policies
Aid for Health
PEPFAR
GFATM, GAVI
Foundation $$
(2000) World Health Report
& MDGs
Child Survival
• USAID – Family Planning• Disease-specific funding
Challenges to Scale Up Services
Source: WHO expert consultation on “Positive Synergies Between Health Systems and Global Health Initiatives (GHIs)” – May 2008
Reform & Financing Caveats
Ideology – Based on Market Principles (1990s - World Bank)
Typical Components of Health Care Reform
58th World Health Assembly (2005)• Adopted the resolution 58.33 on “Sustainable health
financing, universal coverage and social health insurance:”
• Urges WHO’s member states to:– Ensure that health financing systems include
prepayment and risk sharing mechanisms; – Avoid catastrophic health-care expenditure;– Work towards universal coverage = secure access for
all to appropriate preventive, curative and rehabilitative services at an affordable cost
Source: Carrin G, Mathauer I, Xu K, Evans, B. Universal coverage of health services: tailoring its implementation, Bulletin of the WHO, November 2008, 86(11).
What is Health Financing?
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Health Financing Functions
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
NGOs
FBOs
3 Health Financing Functions• Revenue collection:
– Process by which the health system receives money
• Pooling of resources:– Accumulation and management of revenues to share
financial risk associated with health interventions– Prepayment allows pool members to pay in advance, relieves
uncertainty and provides access to compensation if a loss occurs
• Purchasing:– Mechanisms used to purchase and provide services from
public and private providers
3 Health Financing Functions• Raise sufficient and sustainable revenues in an
efficient and equitable manner to provide:– Basic package of essential services– Financial protection against financial loss due to illness or
injury
• Managing revenues to equitably and efficiently pool health risks
• Ensuring the purchase of health services in an allocatively and technically efficient manner
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Fiscal Sustainability
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Domestic Resources for Health Care in Lower-Income Countries (LICs)
Source: WHO expert consultation on “Positive Synergies Between Health Systems and Global Health Initiatives (GHIs)” – May 2008
Health Outcomes and Health Spending
Source: World Development Indicators, 2007
Infant Mortality Rate vs. Total Spending per CapitaInfant Mortality Rate vs. Total Spending per Capita
Public Finance Challenge
Environmental sanitation
Family Planning
Vector control
Maternal and Child Health
OP hospital referrals
Health center OP curative
OP hospital self-referrals
2nd class IP care
VIP IP care
Kidney dialysis
Open heart surgery
Cosmetic surgery
Water supply
Pure Public Goods
Pure Private Goods
Curative
Preventive
Government policy dictates most resources flow here
Actual funding ends up here
RichPoor
Pop IV Project
Health Care Spending in Ghana
85%
Selection of Services to be Financed
Environmental sanitation
Family Planning
Vector control
Maternal and Child Health
OP hospital referrals
Health center OP curative
OP hospital self-referrals
2nd class IP care
VIP IP care
Kidney dialysis
Open heart surgery
Cosmetic surgery
Water supply
Pure Public Goods
Pure Private Goods
Curative
Preventive
Pop IV Project
The richThe poor
BASIC PACKAGE
$34/p/year
Sub-Saharan Africa Expenditures on Health (1997-2000)
Recommended expenditure: >$34/capita (CMH)
Source: World Bank, World Development Report (2004)
Health Financing Functions
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Key Issues of Revenue Collection
• Mobilize enough resources to finance expenditures for basic public and personal health services WITHOUT resorting to public sector borrowing (Tanzi and Zee 2000)
• Raise revenues equitably and efficiently• Various types of organizations eventually
receive funds • Conform with international standards
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Types of Revenue Collection
• Out-of-pocket payments (ex. user fees)• Tax-based financing• Social Health Insurance (SHI)• Voluntary private insurance• Community-based financing
Types of Prepayment
Prepayment makes risk sharing possible…
User Fees
User Fees
• Characteristics:– Pay as you go - no risk pooling– Incentive effects– More resources directly for health
• Evidence:– Can raise significant revenue– Frequent misuse of collected funds– Frequent poor design and planning– Highly political and controversial
Source: Lagarde, M and Palmer, N. The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence? Bulletin of the WHO, November 2008, 86(11).
General Taxation• Characteristics:
– Usually collected by the Ministry of Finance – as main source of revenue and serves the general population.
– Mobilizes funds from everyone regardless of their health status, income, or occupation
– Pools health risks across a large contributing population
• Evidence:– Mildly regressive to progressive – Inequitable access for the poor– Reducing individual responsibility for one's own health?
Source: Tax Based Financing for Health Systems: Options and Experiences, Discussion Paper #4, World Health Organization (2004).
Social Health Insurance (SHI)
• Characteristics:– Mandatory participation– Large risk pools– Social solidarity
• Evidence:– Covers people primarily in formal sector– May increase disparities between income groups
Voluntary Private Health Insurance
• Characteristics: – Risk pooling– Payment based on ability and risk– Access based on payment
• Evidence:– Generally not pro-poor– High-risk subscribers dropped or pay more– Rich capture more benefits
Community-Based Financing• Bamako Initiative (1987) = “Women and children’s
health through funding and management of essential drugs at the community level”
• Characteristics:– Start up funds for basic equipment, provision of basic
drugs, support costs
– Drug charges to recover expenditures – as seed capital and for replenishment
– Community health committees
Health Financing Functions
SCHEIBER, G. "Financing Health Systems" Chapter 12, pp 225-242 in Disease Control Priorities in Developing Countries, 2nd Edition. New York: Oxford University Press 2006.
Pooling and Purchasing
New Health Care Reforms?• Changing role, size, spending in public sector• Transfer of responsibility to, promote expansion
of and regulate NGO services• Addressing the nearly universal difference
between policies and actual expenditure• Integration of services (IMCI, IMAI, IMPAC)• Operations (health systems) research
Community-Based Health Insurance (CBHI)
• Principles:– Small risk pools– Social solidarity on small scale
• Evidence:– Can enhance financial access to limited care– Primarily curative oriented– Geographic inequities (closer is better)– Government’s re-distributive role important– Generally failed to meet expectations
CBHI Evidence BaseGeneral:• evidence base is limited in scope and questionable in quality• the effects are small and schemes serve only a limited section of the population
Specifics:• strong evidence CBHI provides some financial protection by reducing out-of-pocket
spending• moderate strength evidence that such schemes improve cost-recovery. • no evidence that schemes have an effect on the quality of care or the efficiency with
which care is produced• these types of community financing arrangements are, at best, complementary to other
more effective systems of health financing. • Regarding the costs and the benefits of various financing options, the current evidence
base is mute on this point
Ekman B. Health Policy Plan. 2004 Sep;19(5):249-70.
Decentralization
• Transfer of fiscal, administrative, and/or political authority for planning, management and service delivery to lower levels of government.
• Most often done for reasons beyond health
• One pure model does not exist
Fiscal Decentralization
Defines the:• Financial relations between national and sub-national
units of government.• Authority to collect and use revenue• Direction and size of inter-governmental resource flows• Division of power for taxation• Means by which national resources are adjusted to
match local expenditure responsibilities• How national resources flow to achieve equity
Decentralization - Uganda
* Source: Measure Project Akin, John, Paul Hutchinson and Koleman Strumpf “Decentralization and Government Provision of Public Goods: The Public Health Sector in Uganda” March 2001
Your Experiences with Decentralization
• Do local levels have resources that correspond to their increasing authority?
• What are the impediments to effective management at a local level?
• Has decentralization reduced corruption?
BASIC PACKAGE
Where do CBHI schemes fitWhere do CBHI schemes fit
Environmental sanitation
Family Planning
Vector control
Maternal and Child Health
OP hospital referrals
Health center OP curative
OP hospital self-referrals
2nd class IP care
Tertiary IP care
Kidney dialysis
Open heart surgery
Cosmetic surgery
Water supply
Pure Public Goods
Pure Private Goods
Curative
Preventive
Pop IV Project
The richThe poor
CBHI Schemes
now
Public / private collaboration in curative service delivery
SHI -
public/private provision
Financing: Filling the gapsFinancing: Filling the gaps
Pure Public Goods
Pure Private Goods
Curative
Preventive
Pop IV Project
Self-financing Pre-pmt Schemes
The richThe poor
Pure private provision + service contracts
Public provision & finance
Subsidized pre-pmt Schemes
Organizational Forms Ministry of health, usually heading a large network of public providers organized as anational health service, relying on general taxation – collected by the ministry offinance – as the main source of revenue, and serving the general population.
Social security organization (single or multiple, competing or not), mostly relying onsalary-related contributions, owning provider networks or purchasing from externalproviders, and serving mostly their own members (usually formal sector workers).
Community or provider based pooling organization, usually comprising a small pooling/purchasing organization relying mostly on voluntary participation.
Private health insurance fund (regulated or unregulated), mostly relying on voluntarycontributions (premiums), which may be risk-related but are usually not income related, and are often contracted by an employer for all a firm’s employees.
Health Care Reform
• Not enough funds for basic care• Misallocation - 80% of resources tend to go toward richest
10% of population, urban/rural inequities. For example, surgery for cancers rather than FP, treatment of TB, STI.
• Inequity - poor lack basic access to HCare • Inefficiency – in allocation of health workers, purchase of
drugs • Inadequate recurrent budgets - lack of maintenance; logistic
problems; poor quality services; low productivity, poor access
• Little control over local resources – peripheral health facilities often have disproportionately low resources for population served
Life Expectancy and Health Spending
Source: World Development Indicators, 2007
top related