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International Health Financing Policies

J.-P. UngerPublic sector health care unitInstitute of Tropical Medicine, Antwerp, Belgium

A presentation to Medicus Mundi SpainJune, 2013

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Plan 1. International health financing policies in LIC

2.International health financing policies in MIC

3.Alternative options

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1. International policies onhealth care delivery and financing in LIC

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Alleged objectives ofinternational health policy (MDGs)

• Reduce mortality by AIDS, TB, malaria • Reduce maternal and child mortality• Avoid communicable diseases spilling over in HIC

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International health policy forgotten objectives

• Improve equity in access to care• Reduce adult mortality • Reduce morbidity and suffering in children and adults• Control biological and social determinants of illness• Limit spread of resistance to drugs• Control health expenditure

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International doctrine

MOH

private

Disease control programs

X

(x)

Health care

X

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Failure to reach (the quite limited) MDGs and even to progress in LIC• ± 50% of PLWHA needing treatment were receiving the

medicines in 2009 (36% with new guidelines), far from the 100% aimed at in 2010

• TB prevalence in Africa: 1990-2007: +47%• Health care expenditure remains 1st cause of falling into

poverty

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Avoidable mortality and suffering

• 11 million avoidable deaths attributable to communicable diseases yearly

• ± 10 million avoidable deaths due to chronic diseases yearly

• Generalised torture – avoidable suffering in LMIC by lack of access to care and drugs (a human right?)

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Inefficiency of international aid

• More than 120 disease control programs expanded between• Washington, Brussels and Geneva• LMIC capitals, towns and villages of LIC (with VHW)

• The biggest ever created bureaucracy

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Total annual resources needed for AIDS under disease-specific organisation pattern

Funding gap

European Parliament17th March, 2011

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Why this failure to control diseases? A negative feed back loop

1. for success, disease control programmes need patients consulting for various symptoms. They represent a pool of users that disease control programmes need for early case detection and sufficient coverage.

Can malaria be controlled where basic health services are not used? Tropical Medicine and International Health, 2006; 11(3):314-322

2. neoliberal policies allocate patients to private sector and disease control to public

Letter. Public health implications of world trade negotiations. Lancet, 2004, 363: 83

3. while disease control programs limit access to care in public services e.g. polarizing them according to their interests

2003. A code of best practice for disease control programmes to avoid damaging health care services in developing countries Int J Health Planning and Management 2003, 18: S27-S39

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Why has access to health care been left out of international health policies in LICs?

• Not because costs: costs of a few disease control programmes in DCs = costs of family medicine encompassing the same programmes Selective Primary Health Care: a critical review of Methods and Results. Soc. Sci. Med. 1986; 22,

1001-1013

• Because no subsided competition with the private sector is tolerated where there is a demand.

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The international policy undermine LIC health systems

Segmentation and fragmentation of systems

• No more first line individual health care delivery• Proliferation of disease specific programs (52 in

Congo)

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The international policy undermined health systems in LIC

• Limited responsiveness of health systems to respond to users demand and to host disease control programs

• Community participation and support vanished• Poor status of public services professionals• Internal brain drain (LIC++)

2009. International health policy and stagnating maternal mortality: is there a causal link? Reprod Health Matters, 17,33: 91-104

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Overall impact on health care• 1990: almost 50% fail to provide adequate access to care

for their citizens in LIC and MIC UNDP. Department of Economic and Social Affairs, Population Division, United Nations, New York.

ST/ESA/SER.R/151, 2000

• access to care particularly difficult in China, former Soviet Union, Africa

• no recent global data (to our best knowledge)

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2. MIC health policies

Comparing Colombia, Chile and Costa Rica

• Colombia, in vivo test of health care privatisation in developing countries. Int J Health Services

• Costa Rica: Achievements of a heterodox health policy. American Journal of Public Health

• Chile, a neoliberal success story? PLoS

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Old inter-country comparisons

Reduction

IMR IMR IMR MMR

1970 2001 1970-2001 2001Costa Rica 62 9 : 7 29

Chile 78 10 : 8 23Colombia 69 19 : 4 80

Notice: 16% of Chilean population consumes 50% of health expenditure

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Health and Equity Indicators Costa Rica vs United States (2002)

GDP per capita (PPP USD)health expenditure per

capita

Costa Rica

9,460

562

USA

34,320

4,887

infant mortality rate 9 7

life expectancy at birth 78 77

Gini index 46.5 40.8

MIC/US health policies: a universal model

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The new international health policy objective: universal coverage

• Promoted by France, Germany, USA…• And WHO (WHR 2010)• Alleged justifications:

• out-of-pocket expenditure hampers access• chronic diseases become a burden (demographic transition)

• Objective: open LMIC middle class market of health insurance to high income countries banks

• Example: main Chilean Isapres belong to 3 EU / US banks

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Misleading universal insurance coverage

• Colombia 1997-2003: • insurance coverage rate from 54% up to 62% but • outpatient consultation rate 23.8% down to 9.5%

• Peru 2007 – 2008: • social Insurance coverage from 42,7 up to 63,5% in extremely poor population

and from 26.6 to 44.7 in the other but • those who didn’t consult increased from 50.5 to 56%

• Burkina Faso 2008: • Made C-sections free at the point of delivery but• c-section rate up by 20% only

• Ghana 2007 -2009: • insurance coverage increasing from 0% to 60% but • user fees increased from 9 to 11% of total health expenditure

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(Insurance!) universal coverage, a fashionable strategy unlikely to work

All these examples point to the existence of significant non-financial barriers to

• access to individual health care • limited effectiveness of health insurance in LMIC • the lure of focusing public financing on the poor (≠ Western

Europe)

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Why did social health insurances fail in LMIC?

Because•paradoxically, governments focused public financing / social insurance on the poor!•…which led middle classes to deny any contribution to health care public financing as they couldn’t take advantage of it•To the contrary, in Western Europe, social organizations forced a single universal pooled prepayment system

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Why did social health insurances fail in LMIC?Because of limited effectiveness of regulation and control in

LMICs

•Hesvic project: evaluation of regulation in Chinese, Vietnamese and Indian maternal health sectors

8 / 9 = failures; 1 / 9 = central planning•Failure of PFP in Costa Rica•Failure of Chilean and Colombian health policies are partly linked to failures of their ‘superintendencia’ (contraloria)•Mechanisms are related to LIC / MIC States features

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The international policy undermine LIC health systems

Segmentation and fragmentation of systems

• Management property split = commercial privatisation of public hospitals (ex. China)

• Municipalization of health services (from Philippines to Brazil)• Bolivia: 4 authorities (national and local governments, region,

and international cooperation) for 1 health centre

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The hidden motives of this policy

• 16% of GDP (USA) – 8% of GDP (Spain)= 8% of the world GDP

• The biggest worldwide market to earn?

Past and future GDP at market prices (trillions of euro)

2007 2008 2009 2010 2011 2012 2013 2019

EU 12.4 12.45 11.7 12.25 12.6 12.9 13.4 14.4??

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Non health economic actors will lose market shares if Europe health system moves towards a US like one

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Alternative options in health care delivery policies

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A new MDG: universal access to versatile, individual health care• family and community medicine• general hospital care• disease control • integrated control of social determinants

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Instead of insurance coverage indicators, promote indicators of access to decent care

Examples • Hospital admission rates• First line utilisation rates• TB and AIDS case fatality rates• Referral completion rate

None of them are requested by WHO / released by countries!

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Such care should meet simple quality criteria

Care should be

•continuous (to avoid resistance to antiretroviral and TB statics)

•integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs)

•bio-psychosocial (to be effective /acceptable)

•effective e.g. tuberculosis case fatality rate

•Efficient (to be compatible with solidarity)

•Not-for profit (to be compatible with the Hippocratic Oath)

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Promote a health sector with a social mission

Mission(Status)

Social(Government)

Commercial(Private)

MOH Care + Disease control

Care

private Care + Disease control

Care

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Strategic priorities for health systems strengthening1. Integrate and strengthen the sector of publicly oriented

(socially motivated) health care delivery

2. Integrate administration of disease control programs into general health care management

3. Strengthen bio-psychosocial care in first line

4. Strengthen general hospitals

5. Coordinate first line services + Hospital in a local health system to improve care coordination and knowledge transfer

6. Steer field experiments

7. Promote bottom up planning towards national health policy

Addressing fragmentation with integrated networks

H

Interinstitutional management of local health systems

Professional management and deconcentrated budgets are needed

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4. Alternative options in health financing

Let’s not target the poor with public financing if we want national solidarity and equity

Let’s export the principles of the West-European health financing system

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An alternative financing pattern for segmented health systems

Taxes

(or Bismarkian) National health fund

MoH

MoH servicesNot for profit private org.

Commercial sector

Individuals Social sector

Demand-side financing

Notice: supply side financing doesn’t permit to only finance MOH services

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Thank you

jpunger@itg.bewww.jeanpierreunger.com