GETTING OUR SYSTEMS RIGHT

to secureUNIVERSAL HEALTH

COVERAGEPresentation to the 10th Caribbean Health Financing Initiative Conference

Raphael D. Barrett

Providenciales October 2015 Turks & Caicos Islands

WHO PUBLICATIONS ON UHC

World Health Report 2010"Health Systems Financing: A path to universal coverage“

World Health Report 2013“Research for Universal Health Coverage”

PAHO/WB Report 2015“Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries”

WHAT ARE THE KEY PRINCIPLES,

CHARACTERISTICS, INDICATORS OF A HEALTH

FINANCING SYSTEM WHICH REFLECTS UNIVERSAL HEALTH

COVERAGE?

UNIVERSAL HEALTH COVERAGE – WHOUniversal Health Coverage is firmly based on the WHO constitution of 1948 declaring health a

fundamental human right the Health for All agenda set by the Alma-Ata declaration in

1978

Equity is paramount - tracking progress not just across the national population but within different groups (e.g. income, sex, age, place of residence, migrant status and ethnic origin)

The goal of Universal Health Coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them

UHC – WHO Fact Sheet N°395 September 2014

UHC means that all people receive the health services they need without suffering financial hardship when paying for them.

UHC interventions must address the most important causes of disease and mortality whilst delivering the full spectrum of essential, quality health services to improve the health of those receiving the services.

Health Financing mechanisms are a critical factor e.g. pooling funds to spread financial risk across the population, cross subsidies - rich/poor, healthy/sick - increased access.

UHC – WHO Fact Sheet N°395 September 2014 UHC not achieved overnight; all countries can take actions

to maintain gains made and move more rapidly towards it. As Governments find it increasingly difficult to meet the

increasing health service costs and ever growing needs of their populations, key factors in prioritising health services include epidemiological context, health systems, level of socioeconomic development, people’s expectations.

MYTHS about Universal Health Coverage UHC is not just health financing, but covers all components of the

health system to be successful UHC is not only about assuring a minimum package of health

services, but also about assuring a progressive expansion of coverage of health services and financial risk protection.

UHC does not mean free coverage for all possible health interventions, regardless of the cost; no country can provide all services free of charge on a sustainable basis.

UHC is much more than just healthtaking steps towards UHC means steps towards equity, development priorities, social inclusion and cohesion

ACHIEVING Universal Health Coverage A strong, efficient, well-run health system that meets priority

health needs through people-centred integrated care Affordability – a system for financing health services so

people do not suffer financial hardship when using them. Access to essential medicines and technologies to diagnose

and treat health problems. A sufficient capacity of well-trained, motivated health

workers to provide the services to meet patients’ needs based on the best available evidence.

The IMPACT of Universal Health Coverage Access to health services enables people to be more

productive and active contributors to their families and communities.

Financial Risk Protection prevents people being pushed into poverty when they have OOP for health services.

UHC is a critical component of sustainable development, poverty reduction and any effort to reduce social inequities

CARICOM: Nassau declaration of 2001– the Health of the region is the Wealth of the region

WHO: Universal Coverage is the hallmark of a government’s commitment to improve the wellbeing of all its citizens

HEALTH FINANCING FOR UHCGiven the objectives - Access, Financial Risk Protection - health financing mechanisms suitable for UHC must include Encouraging and facilitating the basic principles of

insurance Prepayment – so persons do not faced the full cost of an event

when it occurs but have ‘saved for the rainy day’ Risk sharing – pooled funds allowing persons to share their risk

Mandatory participationGovernment intervention, directly or indirectly, is necessary To ensure the largest insurance pool – the total population To avoid selective participation – persons staying out until they

need services

TO WHAT EXTENT ARECARIBBEAN HEALTH FINANCING

SYSTEMSGETTING CLOSER TO OR FARTHER

FROMUNIVERSAL HEALTH COVERAGE?

PROVIDING & FINANCING Caribbean Health Services

ServicesProvision/Agencies

Financing

Public health Public Taxes/budget

Ambulatory care(GPs, Specialists)

Public, PrivateOOP; taxes-budget, insurance, NGOs

Inpatient Care Public, PrivateTaxes-budget, OOP, insurance, grants

Drugs & Diagnostics

Public, PrivateOOP, insurance, taxes-budget, NHF

Overseas care Public, PrivateInsurance, OOP, taxes-budget, grants

Training-Research Public, Private Taxes-budget, OOP, grants

NOTE: All countries have a high level of Out-Of-Pocket payments (avg = 28%)

CARIBBEAN HEALTH FINANCING SYSTEMSTable was prepared by Dr Stanley Lalta, 2015 (source: WHO/WB, 2012)

Govt Tax/Budget (>60%)

SHI (>60%) Hybrid - Govt/SHI

1 Anguilla* Bermuda* Antigua

2 Barbados Cayman Is* Bahamas

3 Belize Turks & Caicos Is* Haiti

4 Dominica Aruba* Jamaica

5 Grenada Bonaire-Saba-Statia* Surinam

6 Guyana Curacao* Trinidad

7 Montserrat* St Maarten* Virgin Is. (UK)*

8 St Kitts

9 St Lucia

10 St Vincent

* Data from country papers at Caribbean Health Financing Conference)

HEALTH FINANCING PATTERNS IN THE CARIBBEAN

Caribbean Total Health Expenditure (THE) (WHO/WB/Other..2012 database)

Average THE = 6% GDP

Average per capita expenditure US$600

Public spending – up to 66% thru taxes/budget funds and compulsory SHI in some countries

Private spending – typically 32% of THE thru direct payments, private insurance and NGOs

High OOP - average 75% of private spending; 25% of THE

Low external support - <2% (except Haiti)

HEALTH SERVICE PROVISION IN THE CARIBBEAN

Health Services are provided by a mix of Public & Private facilities Public sector - dominant in public health, inpatient services,

research/training Private sector - dominant in ambulatory care, drugs &

diagnostics and overseas care for critical and complex cases

Patients utilise both facilities with noticeable tiers:d more low income groups at public facilities;

d middle and high income groups at private facilities;

d very high income and insured persons at overseas facilities.

CARIBBEAN INITIATIVES TO IMPROVE HEALTH SERVICES

Examples of initiatives taken to expand and improve access, coverage and service provision of national health systemsAntigua & Barbuda

Medical Benefits Scheme 1972

Medical care - contributors

Barbados Barbados Drug Scheme 1980

Specific drugs; conditions - citizens

Aruba AZV [Social Health Insurance] Specific drugs; conditions - contributors

Curacao National Health Plan 1994

Specific drugs; conditions - contributors

Sint Maarten AZV [Social Health Insurance] Specific drugs; conditions - contributors

Jamaica Jamaica Drugs for the Elderly ProgrammeNational Health Fund

1996

2003

Specific drugs; conditions - residents

Belize National Health Insurance 2001

Specific drugs; conditions - contributors

Trinidad & Tobago Chronic Disease Assistance Programme 2004

Specific drugs; conditions - residents

St. Lucia Universal Health Care 2005

Medical care - residents

Bahamas National Prescription Drug Plan 2010

Specific drugs; conditions – contributors

Turks & Caicos National Health Insurance 2010

Specific drugs; conditions – contributors

NCCD – 54% Communicable – 20%Injuries – 11% Other – 15%Cardio – 52% Cancer – 15%

NCCD – 74% Communicable – 14%Injuries – 10% Other – 2%Cardio – 36% Cancer – 17%

WHAT REFORMS/MEASURES SHOULD BE IMPLEMENTED TO ADDRESS GAPS

IN HEALTH FINANCING SYSTEMS

FOR UNIVERSAL HEALTH COVERAGE?HOW TO MANAGE THE

POLITICAL/STAKEHOLDER INTERESTS WHICH INFLUENCE SUCCESS?

ISSUES FOR UHC IN THE CARIBBEAN Structural

Small populations and economies vulnerable to natural disasters and global economic shocks

High dependence on tourism subjecting population to exposure to travel-borne diseases

Growing inter-island population movement exposing some states to high migrant influx

Technological low economies of scale make the purchase of technologies

very expensive, per capita

Due to small populations utilisation of complex, expensive services low making it difficult to retain trained staff

ISSUES FOR UHC IN THE CARIBBEAN

Demographic and Social aging population; increased migration of working age

population

growing health expectations – ready exposure to systems and services available elsewhere

Epidemiological dominant CNCD (1 in 3 persons)

infectious diseases – HIV, re-emerging conditions e.g. TB, Malaria

ISSUES FOR UHC IN THE CARIBBEAN Macroeconomic and Fiscal

Low economic growth rates and recession Fiscal constraints – budget/current account deficits; high debt burden Double digit unemployment and poverty rates Eligibility for external funds – many countries now classified as

‘middle income’

Financing Has to be mandatory as solidarity is low How to increase finances for health – taxes, contributions Better management and utilisation of pooled funds Better integration with private health insurance

ISSUES FOR UHC IN THE CARIBBEAN Operational

Improper use of Secondary Emergency Services Primary Care facilities

Leakage of supplies, medicines, labour Issues implementing results-based provider payment systems:

Private systems tend to favour cost based fee-for-service Public systems tend to favour inputs-based budgets

Politics Greater demands for complicated/expensive services Should healthcare be removed from profit motive if it is designated

a human right?

ISSUES FOR UHC IN THE CARIBBEAN Coverage

Most countries seek to restrict coverage to citizens due to the cost of providing for immigrants and the legal implications

Concerns re non-citizens Have little or no political clout as they often do not have a vote Are seen as an immigration/security problem rather than the

economic contributors they are, e.g. low paid jobs sometimes with mandatory statutory contributions

Size in relation to the “belonger” population: Bahamas, TCI

ISSUES FOR UHC IN THE CARIBBEAN Removal of user fees – “free health care”

‘free health care’ often results in lower quality/standards of services due to irrational demand

Meets the UHC standard for access but is not equitable if it reduces revenues from those who can afford some payment

has been difficult to counter politically – ‘freeness mentality’ has resulted in less financial resources for the sector and

greater demands on the system less rational use of services with patients bypassing primary

health services in favour of secondary facilities

BAHAMAS NEWS EXTRACTS“The Bahamas Insurance Association has always been committed to implement UHC in a manner that is affordable, sustainable and least disruptive to the industry and economy at large…

…the Prime Minister had indicated that NHI will be the ‘single biggest development’ in the Bahamas, post-independence…

…we do not want to fight with the Government on a progressive social initiative that is designed to serve the best interest of the Bahamian people…

…after all, we all support the principle of universal healthcare.”

Private sector stakeholders

believe

PricewaterhouseCoopers has

advised the Government to

take a completely different

approach to healthcare

reform and adopt an

ObamaCare-style plan…

…rather than go with an all-

encompassing NHI model…

coverage would be offered

through private insurers,

with subsidies for those who

can’t afford the premiums.”

HEALTH FINANCING FOR UHC1. Need to understand that health financing being a national issue does

not imply or mean 100% government financing

2. The government’s role should be coordinator, facilitator and subsidiser for specific groupings determined, preferably, economically

3. Establishing pooled funds enhances the insurance function by spreading risks and contributions over the largest pool – the total population

4. There needs to be better administration of pooled funds so that they are autonomous in the collection and management of their finances

5. More use of dedicated taxation for health – ‘sin taxes’, visitor health fee

6. Benefit structures need to be patient centric – economically enabling patients thereby giving them choice

THANK

YOU