Financing for

UniversalHealth Coverage (UHC)

EPHP 2010

Bart Criel Institute of Tropical Medicine

Antwerp, Belgium

Contents

What is UHC about?

World Health Report 2010

Health systems financing: the path to universal coverage

What are the challenges for Indian policy-makers?

Which role for what kind of research?

Which way forward towards towards UHC?

UHC: what is it about?

Everyone should be able to access health services and not be subject to financial hardship in doing so

Call for UHC consistent with…Alma-Ata declaration (1978)

World Health Assembly resolution 58.33 (2005)

World Health Report PHC, now more than ever (2008)

Commission on Social Determinants of Health report (2008)

…

Changing global policy environment

• Sociological changes– Growing public demand and expectations– More vocal civil society

• Medical-clinical changes– Epidemiological transition: NCD, aging,… with

increasing costs of health care– New treatments

• Policy / Political changes– Equity (back) high on the agenda (following SDH)

Use of curative care consultation as indicator for access: facts are stronger than a Lord Mayor

• Average sub-Saharan country

- less than 0.5 contacts per capita per year at level of first line health services

- less than 10 hospital admissions per 1000 inhabitants per year

-> considerable under-utilisation (of modern care in formal services)

• Belgium: approx. 10x higher

- 4 to 5 contacts per capita per year at general practice level

- 150 hospital admissions per 1000 inhabitants per year

Health care financing needs

What to do (in low-, middle- and high-income countries)?

1. Need for more resources

2. Need to raise them in a more fair manner

3. Need to spend / allocate these resources

in a more efficient way

How much is spent? How much needed?

OECD countries spend on health on average US$ 3600 per capita per year

31 of WHO’s member states spend less than US$ 35

4 member states spend less than US$ 10

India spends approximately US$ 50, of which 80% isout-of-pocket

Recent estimates of financing needs:

On average US$ 60 per capita per year will be needed in 2015

(including antiretrovirals and care for non-communicable diseases)

Limitations of direct payments

• Direct payments (user fees, out-of-pocket payments)– Regressive by nature– Deter poor people from (needed) utilisation– Source of impoverishment

• Dr Margaret Chan:User fees have punished the poor

• Exemptions often do not work– Loss of income for providers– Stigma, discriminating behaviour, bureaucracy

More OOP in poorer countries…

Source:

WHR 2010p42

…and higher risk of impoverishment

In terms of catastrophic health expenditure, and ultimately in impoverishment

Source:

WHR 2010p43

Non-financial barriers also matter

Distance

Culture, language, gender

Perceived quality of care…

Discriminatory practices

Stigma

Lack of information…

J.T Hart (The Lancet, 1971): the inverse care law

The availability of good medical caretends to vary inversely with the need for itin the population served

‘Omnio’ programme in Belgium

Belgium: 15% of its population is ‘BPL’

Omnio is a government programme that aims at enhancing financial access to health care in Belgian Social Health Insurance system for highly vulnerable population groups

Benefit for BPL: reduced co-payments when using care

Only 25% of total entitled population (800.000 HH) makes use of Omnio after several years of operation

Why?

• Lack of information

• People have to apply for it themselves

• Complex administrative procedures

The medical poverty trap

Poverty ill health Poverty

- Poor access to quality care

- Social Determinants of (ill) Health

- Catastrophic Health Expenditure

- Lack of Social Protection in Health

1. Need for more resources

• Increase efficiency of revenue collection• Reprioritise government budgets• Innovative financing• Development assistance for health

2. Remove financial barriers to access

• Prepayment and pooling– Subsidise for the poorest– Ideally, mandatory contributions– Go for large numbers of people pooling funds

1. Who is covered from pooled funds? Breadth2. What services are covered? Depth3. How much of the cost is covered? Height

Breadth of coverage

Height of coverage

Depth of coverage

Source:

WHR 2010p12

3. Promoting efficiency and eliminating waste

• According to the 2010 World Health Report, about 20-40% of resources spent on healthare wasted– E.g. drugs– Provider payment systems– …

Change is possible: yes, we can

Countries with similar levels of health expenditure achieve sometimes strikingly different results

No single mix of policies works well in every setting

Need for home-grown strategies

- Path-dependency

- Pragmatism vs dogmas

- No copy and paste

‘Succes stories’

Brazil, Chile, China, Mexico, Rwanda, Thailand, Gabon, Cambodia, Lebanon, Ghana…

…have made substantial progress

The ‘Triangle that Moves the Mountain’

Relevant knowledge via

research

Social movement

Political involvement

The Thai example

The case of India

• Underfunded government health sector: government expenditure on health is 1% of GDP

• Bulk of health care expenditure in India is OOP• Fragmented health system: the main divides

– Public-Private– Clinical Medicine - Public Health – Horizontal – Vertical

Policy priorities in India

Messages for policy-makers– More financial resources

• Increase funding to public sector

– More resources raised in a fair way

• Reduce reliance on direct payments and shift further to prepayment and pooled funds

– More efficient use of scarce resources

• Rationalisation measures at supply-side of care

A number of current public programmes already go in that direction: – NRHM (Health)

– RSBY (Labour)

…

Need for a systemic approach for synergy

1. Enhance accessLift barriers to care - financial and others

2. Rationalise the provision of care

ResourcesProvider behaviour

3. Organise and manage local health systems with a clear vision in mind

Pluralistic and integrated systems based on Primary Health Care

1. Demand-side interventions

2. Supply-side interventions

3. Management of the Local Health System

The intervention

triade

1st Global Symposium on Health Systems ResearchMontreux, Switserland, 16-19 November 2010

Universal health coverage with equity:what we know, don’t know and need to know(Frenz & Vega, background paper) www.hsr-symposium.org

Messages for researchers:

Important gaps in knowledge about why health needs for some groups are not being met by UHC programs… Research should go beyond just reporting inequities in health care utilisation to explaining the causes of differential access

Need for a more comprehensive understanding of equitable care, which integrates a sociological perspective and uses mixed quantitative and qualitative methodologies

Research on CHI in India: not only an effective strategy, also a social investment

Community health insurance contributes to universal health coverage in India

PhD thesis 2010 (Devadasan)

If well designed and implemented, CHI schemes in India can increase access to hospital care and protect households from Catastrophic Health Expenditure

Community Health Insurance and Universal Coverage: Multiple paths, many rivers to cross

World Health Report (2010) Background Paper 48(Soors, Devadasan, Durairaj and Criel)

Research in Mumbai and Pune confirms the potential for bottom-up empowering of CHI members

The government – in addition to its top-down approach – should tap the potential of community organisations to transform the RSBY target groups from passive beneficiaries into active participants

Socially Inclusive Health Care Financing in West Africa and India (Health Inc.): a EU-funded research project

Hypothesis:Social exclusion is an important cause of the limited success of recent health financing reforms

Health Inc. will analyse:

(i) whether financing arrangements can overcome social exclusion to successfully cover poorer population groups

(ii) whether these arrangements succeed in increasing social inclusion by empowering socially marginalised groups.

Fields: India (Karnataka, Maharashtra)Ghana Senegal

Partners: India: IPH Bangalore & TISS MumbaiGhana: ISSER AccraSenegal: CREPOS DakarEurope: LSE London & ITM Antwerp

Start:May 2011

Way forward: what is needed?

• More resources• More fairness in raising these resources• More efficiency in using these resources

But financing is a means to an end:What are the resources for?

• Need for a clear and shared vision on how to organise (local) health care delivery systems that offer accessible quality care to all who need it

Thank you

5 presentations

• Gautam Chakraborty: Patterns of Public Health expenditure in India: Analysis of State and Central Health Budgets in pre- and post-NRHM period

• K. Gayithri: District fund flow under NRHM and service delivery. Some insights from Karnataka

• KG Santhya: Conditional cash transfers and quality of care of maternal and newborn care. Womens’ experiences of Janani Surksha Yojana in Rajastan

• Sulakshana Nandi: A study to analyse implementation of RSBY in Chattisgarh

• Shridar Kadam: A Rapid Evaluation of the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh

3 posters

• Sapna Surendran: Effective utilisation of National Rural Health Mission Flexi-funds in Jharkand: Facilitators, Barriers and Options

• N Devadasan: Performance of Community Health Insurance in India – findings from empirical studies

• Manoja Das: Janani Suraksha in Jharkhand. Detreminants of utilisation of conditional cash transfer scheme and institutional delivery