Shaping UHC Policy for Post 2015:Opportunities & Risks

Jeanette Vega MD, DrPHManaging Director of Health

NHIS 10 Anniversary Conference Accra, November 4th, 2013

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Universal Health Coverage (UHC) contribution to the Sustainable Development Goals

UHC: Definition and components

Health financing situation in Africa

Presentation Overview

Achievement of MDGs in the region

Concluding remarks

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Universal Health CoverageHealth promotion, prevention, treatment, financial risk protection.

Healthy Lives at All StagesChild survival, maternal survival,MDG6, adolescent health, NCD burden reduction.

Sustainable Wellbeing for AllPoverty eradication, health, education, nutrition, environment, security, etc.

Health SectorContribution

Other Sector Contributions

Post-2015 Development Agenda: Wellbeing for AllThe contributions of the health sector and other sectors

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Universal Health Coverage: What?

Indicators: 1. Financial protection2. Access

All people can access the health services they need without incurring financial hardship.

Definition:

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Financing for UHC: Overall questions to be addressed by any country

How to alter the system in a way that– Reduces the gap between the need for and use of services,

across the population, – Improves quality of health services, – Improves financial protection…

… given our starting point in terms of– existing configuration of the health system, including coverage

arrangements, – overall current and expected fiscal constraints, and– other key contextual factors, such as labor market (informality), public

administration structure (e.g. decentralization), geography and population density, politics, etc.?

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Policy options for universal funding coverage

Fund coverage for everyone secured from general budget revenues, automatic entitlement: Non- contributory

100% Contributory: No subsidy; everybody must contribute a “full premium” or has no entitlement

Guarantee (fund from budget) certain services for all; entitlement to “full package” requires contribution– Complementarity between direct contributions and

government subsidies for coverage expansion

Subsidized participation with strong public commitment to universality

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Two conditions for financing UHC when using contributory arrangements

Subsidization: because some will be too poor or too sick to be able to afford coverage

Compulsory contribution: because some who can afford it are unwilling to pay for it

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One without the other won’t work (subsidies alone not sufficient because rich/healthy will not join; and

compulsory without subsidies imposes a heavy burden on the poor and sick)

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Some broad lessons on health financing policy

No country gets to UHC via voluntary health insurance

– Compulsory or automatic entitlement is essential, with subsidies

All countries with universal health coverage rely in whole or in part on general budget revenues

– Because there are always some who can’t contribute directly,

– And the larger the informal sector, the greater the need for using general revenues

Need to manage resources efficiently: Strategic purchasing is essential

– Move away from the extremes of provider payment methods – unmanaged fee-for-service and rigid line item budgets – as these contribute to system inefficiencies

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Common elements of few countries that have high coverage with “voluntary”contributory schemes

Cost of the “premium” much less than the perceived value of the benefit, stimulating demand

– Substantial subsidies on the supply side and the demand side, and same benefit package as rest of population in the scheme

– Population aware that not being covered means risk of high out-of-pocket spending

Strong role of local governments– Strong incentives/instructions for local officials to inform people and

enroll them into the coverage program, (ie. Rwanda), and– Explicit role for local budgets to subsidize (ie China)

Very strong (authoritarian) governments able to implement these measures

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ChadKenya

CongoGabon

Guinea

Nigeria

Guinea-Bissau

Burundi

Cameroon

Seych

elles

Benin

UgandaNiger

GambiaGhana

Mali

South Afric

a

Comoros

Lesotho

Togo

Malawi

Rwanda0

5

10

15

20

25

Ghana is higher than the average globally

Average per country globally =11.5%, Ghana= 11,9%

African governments increasingly giving priority to health.

Heal

th a

s a %

of g

over

nmen

t exp

endi

ture

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African countries have low public spending on health relative to the size of the economy

Ghana is lower than the average globally =2.6%

Eritrea

Cameroon

Guinea

Guinea-Biss

auGabon

Kenya

C?te d'Ivoire

Nigeria

Angola

Mauritius

Gambia, The

Benin

Uganda

Equatorial G

uineaGhana

Ethiopia

Mozambique

Burundi

United Republic

of Tanza

niaNiger

Namibia

Botswana

Mali

Algeria

Mauritania

Burkina Faso

Sierra Le

one

Seychelle

s

Senegal

South Africa

Togo

Djibouti

RwandaLib

eria

Malawi

Lesotho

0

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2

3

4

5

6

7

8

9

10

Source: WHO estimates for 2011

Tota

l gov

ernm

ent e

xpen

ditu

res o

n he

alth

as a

% o

f GDP

Average per country globally= 3.9%

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It matters because higher public spending on health reduces dependence on out-of-pocket spending

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In summary: two critical issues to increase financial access coverage in Africa

All people can access the health services they need without incurring financial hardship.

How to increase overall fiscal space for health and increase health as a priority in the general budget

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How to advance towards pre-paid Universal financial coverage

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Achievement of MDGs in the region

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Reduce by two-thirds the <5 mortality rate between 1990 and 2015

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Reduce by three quarter the maternal mortality rate between 1990- 2015

Target : 213 per 100,000 livebirthsOnly 2 countries

on track:EritreaEquatorial Guinea

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Maternal health: Increase % of skilled birth attendance to 80%

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One reason for no achievement has been the absence of UHC as a goal in the current objectives

Universal Health Coverage is an integrated, efficient approach to improve health outcomes. It is aspirational, but

there is growing global and national commitment to UHC.

UHC reflects health sector’s inherent responsibility to provide universal and equitable access to health that ensures improved health outcomes.

UHC links to other sectors, and enables healthy, sustainable development.

UHC is a recommitment to health as a human right.

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Why UHC in the Post 2015 Development Agenda?

When designed with an equity, rights and fiscally prudent focus, UHC

is an accelerator towards better health outcomes and overall

social wellbeing.

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MDGs + more ambitious health outcome targets. – E.g., ending preventable maternal and child deaths, universal

access to reproductive health, new HIV, TB, malaria targets, NCDs and their risks.

Universal health coverage emerging as the specific health sector contribution to health

Equity – realizing the right to health for all.

Recognition that achieving health outcome targets a require actions beyond the health sector – determinants of health.– E.g. income distribution, education and labor policies, food

security and nutrition, water and sanitation, urbanization.

Emerging Consensus on Health in the Post-2015 Development Agenda?

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Processes Feeding Into the Post-2015 Development Agenda

Source: UN Foundation and Dalberg analysis