FINANCING

Financing

Source. World Health Report 2010

Dimensions of reforms for UHC: 1) Population coverage, 2) health service coverage and 3) cost coverage.

Health insurance coverage

Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue-4/issuetoc?campaign=woletoc

Financial catastrophe• In the Asia Pacific region, an estimated 105 million people

suffer financial catastrophe, and more than 70 million are impoverished, because of health care costs.

• In 2009, an estimated 3.8 % of total households in Mongolia experienced catastrophic health expenditures, spending more than 40% of their household subsistence income on health.

• As in many LMIC, the high share of OOP in health financing in Mongolia negatively affects equity, access and use of health services.

Source bullet 1: WHO Regional Office for Western Pacific (2009). Health financing strategy for Asia Pacific region (2010-2015). (Quoted in 2016 WPRO Regional UHC Action PlanSource bullet 2: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015 quoting Ministry of Health (2009) – Policy brief: Distribution of health payments and catastrophic expenditure in Mongolia.

Out of Pocket (OOP) expenditure

Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue-4/issuetoc?campaign=woletoc

Reducing OOP• Reducing OOP requires addressing its driving factors,

including:– The irrational use of medicines and pricing practices, at least for

essential drugs included in the health insurance benefit;– Insufficient private sector regulation that has contributed to cost

escalation and growing pressure on all revenue sources.

• Consumers are not always aware of their service benefits and copayment obligations under these two fragmented arrangements (health insurance and government health budget). Patients may pay OOP even for publicly-funded health services and medicines.

Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015 quoting Ministry of Health (2009) – Policy brief: Distribution of health payments and catastrophic expenditure in Mongolia.

Extent to which costs are covered for particularly vulnerable groups

Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue-4/issuetoc?campaign=woletoc

Indirect costs• Study of 39 LMIC: On average, transportation costs were 12% of per-visit treatment charges

for outpatient services and 17% of inpatient treatment charges for hospitalization.

• WHO (2015) study in Mongolia: The poorest of poor use mostly primary health care facilities rather than the specialized centres and clinical hospitals of tertiary care level. Despite being relatively limited, the use of private health facilities increased for the poorest population in Mongolia. They attend Soum and Family health centres twice more than the richest people and 5-10 times less the private hospitals. The richest people accessed health services at central clinical hospitals and specialised centres 2-3 times more than the poorest people.

• Dorjdagva J et al (2016) about Mongolia: lower income groups are less likely to access specialized services at the higher referral levels due to direct costs, including for co-payments, medicines, and consultations, as well as indirect costs, such as for transport and meals.

Source: Saksena, P., et al (2010). Health services utilization and out-of-pocket expenditure in public and private facilities in low-income countries. World health report. http://www.who.int/healthsystems/topics/financing/healthreport/20public-private.pdf Source: Dorjdagva J et al (2016). Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health. 2016, https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0395-8

Cambodia’s Health Equity Funds (HEF)

- Autonomous, district-based schemes

- Reimburse public health facilities for user-fee exemptions provided to the poor

- Subsidize transport and food costs

- Coverage: 90% of the poor population (2014)

- Finance: development partners + domestic funding

Source: Universal Health Coverage: Moving Towards Better Health – Action Framework for the Western Pacific Region. Manila: World Health Organization Western Pacific Region; 2016.

Photo credit: Angela Savage/IPS

Financing for progressive universalism even in the context of economic downturns

• Mitigating the pressures posed by economic downturns requires:

– weighing short-term cut-saving measures against longer-term priorities; – avoiding arbitrary cuts to coverage, budgets, infrastructure, staff numbers,

etc, which are unlikely address underlying performance issues and may cost the health system more in the longer term;

– securing financial protection and access to health services as a priority, especially for the most disadvantaged subpopulations;

– focusing on promoting efficiency and cost-effective investment; – reviewing the health financing policy design and considering who will be

left out by the changing social context and existing approaches to entitlements;

– strengthening cross-sectoral cooperation (in particular with social and fiscal policy domains) to address factors outside of the direct control of the health sector.

Source: WHO Regional Office for Europe (2014b). Economic crisis, health systems and health in Europe: impact and implications for policy. Sarah Thomson, et al. http://www.euro.who.int/__data/assets/pdf_file/0008/257579/Economic-crisis-health-systems-Europe-impact-implications-policy.pdf

Reducing unnecessary expenditure on medicines and using them more appropriately, and improving quality control, could save countries up to 5% of their health expenditure (Source: WHR 2010).

Increasing efficiencies – tackling unnecessary expenditures on medicines

(extracted top 3 only)

How could reinforcing the financial protection improve the health of disadvantaged subpopulations?

UHC Action Framework for Western Pacific: example areas• 3.1.1a. Increase prepayment on health, including through government general revenue and

statutory health insurance, and reduce the service cost to patients.• 3.1.1b. Use prepayment to minimize catastrophic expenditure for life-saving interventions.• 3.1.1c. For population-level health services, target underserved populations, areas or

health conditions.• 3.1.1d. For individual-level services, introduce subsidies for both direct and indirect costs to

improve health service uptake by those who cannot afford to pay […]• 3.1.1e. Reduce fragmentation of financing schemes and benefit packages to maximize

solidarity.

How could reinforcing the financial protection improve the health of disadvantaged subpopulations?

UHC Action Framework for Western Pacific: example areas• 3.1.2a. Understand the impacts of health financing and social protection schemes,

especially for vulnerable populations like older people, women, those with disabilities, children and the poor.

• 3.1.2b. Build potential synergies by linking financial protection mechanisms in health with broader social protection mechanisms.

• 3.2.2b. Provide targeted financial incentives, including vouchers or conditional case transfers, matched with adequate supply to improve use, especially of preventive and routine services.

GOVERNANCE

Source: WHO Regional Office for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Manila: World Health Organization; 2016.

Quality Efficiency Equity Accountability Sustainability and resilience

• Regulations• Effective,

responsive services

• Individual, family and community engagement

• Health system architecture

• Incentive for appropriate provision and use of services

• Managerial efficiency and effectiveness

• Financial protection

• Service coverage and access

• Non-discrimination

• Government leadership

• Partnerships• Transparent

monitoring and evaluation

• Public health preparedness

• Community capacity

• System adaptability and sustainability

AccountabilityAction Domains:4.1 Government leadership and rule of law for health

4.2 Partnerships for public policy

4.3 Transparency, monitoring and evaluation

a. Set the vision for health sector development and ensure sufficient resources for healthb. Strengthen the rule of law and regulatory institutionsc. Build leadership and management capacities

a. Secure intersectoral collaboration across governmentb. Work with non-state partners on shared interests for healthc. Empower communities to participate in decisions and actions that affect them

a. Develop efficient health information systems and streamline information flowsb. Foster open access to informationc. Strengthen institutional capacity for health policy and systems research and

translation of evidence into policy

• Urged Member States, among other things, to:– “Prioritize health system strengthening for UHC,

with a special emphasis on the poor vulnerable and marginalized segments of the population”;

– “Cooperate across government sectors to tackle social, environmental and economic determinants of health, to reduce health inequities, in particular the empowerment of women and girls, and contribute to sustainable, including “health in all policies” as appropriate”;

• Emphasized the need for community engagement.

Government leadership: WHA Resolution 69.11 Health in the

2030 Agenda for Sustainable Development

Cooperation with other sectors

Registration issues(example of Mongolia)

• Situation Analysis Survey of ADB in 2010: – Only 25% of unregistered residents could obtain health

services while 62.2% of registered residents can. – One third of the respondents did not access primary care

when they needed to because of: • a lack of money (77.5 %), • no health insurance (55.9%), and • being too far away (31.8%).

– The government has taken actions to improve the civil registration system through social welfare programmes and targeted interventions. This helps rural–urban migrants to be registered and improved access to health services.

Source: WHO (2013). Health Systems in Transition: Mongolia Health Systems review. Asia Pacific Observatory on Health Systems and Policies. http://www.wpro.who.int/asia_pacific_observatory/hits/series/Mongolia_Health_Systems_Review.pdf

Participation• UHC Action Framework for Western Pacific: example areas

– 1.3.1b. Create a platform for individuals, mass media and health advocacy groups to exchange information and engage with providers and relevant stakeholders.

– 1.3.2a. Establish a system for families and communities to give feedback on the patient journey, for example through patient experience surveys.

– 1.3.2b. Institute conciliation and resolution mechanisms for medical error, complaints and concerns, with involvement of affected patients’ representatives.

– 1.3.3b. Promote the creation of peer support groups to share knowledge and experience.

Source: WHO Regional Office for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. Manila: World Health Organization; 2016.

Redress mechanisms

Source: Feedback Matters: Designing Effective Grievance Redress Mechanisms for Bank-Financed Projects. Part 1: The Theory of Grievance RedressWorld Bank’s Social Development Department, 2011http://documents.worldbank.org/curated/en/342911468337294460/The-theory-of-grievance-redress

• Well-designed and -implemented Grievance Redress Mechanisms (GRMs) can enhance operational efficiency, accountability and transparency ways including: – generating public awareness about services, entitlements and

obligations;– deterring fraud and corruption; – mitigating risk; – providing staff with practical suggestions/feedback that allows

them to be more accountable, transparent, and responsive to beneficiaries;

– assessing the effectiveness of internal organizational processes; and – increasing stakeholder involvement.

Redress mechanisms

Source: Feedback Matters: Designing Effective Grievance Redress Mechanisms for Bank-Financed Projects. Part 1: The Theory of Grievance RedressWorld Bank’s Social Development Department, 2011http://documents.worldbank.org/curated/en/342911468337294460/The-theory-of-grievance-redress

Information and transparency• UHC Action Framework for Western Pacific: example areas

– 4.3.2a. Establish mechanisms and a legal environment for fostering access to information generated by governments, health facilities, insurance organizations and procurement agencies.

– 4.3.2b. Make data available on financial resources, expenditures, health service indicators and health indicators in a timely manner and user-friendly formats to improve health system performance.

– 4.3.2c. Engage civil society organizations and communities in a participatory process for data generation, interpretation and transfer.

Source: WHO Regional Office for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. Manila: World Health Organization; 2016.

Transparency: Knowing the issues to be addressed

(example from European Union countries)

• A European Commission study on corruption in the health sector conducted in 2013 developed a typology of six main types of corruption: – bribery in medical service delivery (informal payments), – procurement corruption, – improper marketing relations (generally between

physicians and industry), – misuse of high level positions, – undue reimbursement claims (insurance fraud), and – fraud and embezzlement of medicine and medical

devices (European Commission, 2013). • Their method of measuring corruption included

collecting and analyzing 86 “cases” of corruption in European nations and interviewing key informants. Source: European Commission (2013). Study on Corruption in the Healthcare Sector. European Commission – Directorate-General Home Affairs. Brussels.

https://www.stt.lt/documents/soc_tyrimai/20131219_study_on_corruption_in_the_healthcare_sector_en.pdf

Transparency and accountability issues – example impact on the MDGs

Source: Vian T and Noguchi J (2014). Corruption in the Health Sector: Implications for Economic Development. A sectoral assessment prepared as input to the OECD study Consequences of Corruption at the Sector Level and Implications for Economic Development.

Participation Participation

Participation

Accountability Accountability

Accountability

TransparencyTransparency

Transparency

InformationInformation

Information

Resilience

Setting strategic directions - Planning – Financing – Regulation – Purchasing –

Inspection, audit, evaluation

Direct public and private health

service providers – Pharmaceutical

industry and suppliers – Training

institutions – Research institutions

– IT solutions

Consumer and patient

associations – Parliamentary

groups and elected citizen

representatives

Types of relationships:- Laws and regulations- Hierarchy / autonomy- Fund flows / financing

mechanisms- Contracts and incentives- Supervision, reporting,

monitoring- Evaluation

Source: Elaborated by Myriam Bigdeli (WHO Governance team/HQ) based on Brinkerhof and Bossert.

How can governance be strengthened to improve the health of disadvantaged subpopulations?

UHC Action Framework for Western Pacific: example areas• Government leadership and rule of law• Regulations and regulatory environment (e.g., private sector costing of services)• Individual family and community engagement• Managerial efficiency and effectiveness• Partnerships for public policy• Transparent monitoring and evaluation