structure and governance of financing - tamas evetovits, who
TRANSCRIPT
Division of Health Systems & Public Health
Spending on health and
financial protection: Why and how?
Dr. Tamás Evetovits
Head of Office
WHO Barcelona Office for Health Systems Strengthening
Tallinn, 1 December, 2016
Improving the dialogue between
health and finance: why and how?
Health officials:
Give us more money,
we know how to
spend it well.
Finance officials:
Improve efficiency first
and then we may give
you more
Make a better case for
more public spending
on health
Understand poverty
and health impact of
high out-of-pocket
spending
How do we know what is
not sufficient level
of spending on health?
AT
BE
BG
CYCZ
DK
Estonia
FI
FR
DE
EL
HU
IE
IT
Latvia
LT
LU
MT
ND
HR PL
PT
RO
SK
SIoveniaES
SE
UK
0
1000
2000
3000
4000
5000
6000
7000
0 50 100 150 200 250 300
Per
cap
ita t
ota
l h
ealt
h e
xp
en
dit
ure
(in
tern
ati
on
al
PP
P)
Male amenable mortality
Men
AT
BE
BG
HR
CYCZ
DK
Estonia
FI
FR
DE
EL
HU
IE
IT
Latvia
LT
LU
MT
ND
PL
PT
RO
SK
SloveniaES
SE
UK
0 20 40 60 80 100 120 140 160 180
Female amenable mortality
Women
Source: Jonathan Cylus using GHED and WHO Mortality database, 2015
Lower spending on health leads to worse health outcomesHigher spending improves health outcomes up to a point
0
5
10
15
20
25
30
Slo
ve
nia
Ne
the
rla
nd
sA
ustr
iaM
alta
Un
ite
d K
ing
do
mS
pa
inD
en
ma
rkC
ze
ch
Re
pu
blic
Lu
xe
mb
ou
rgS
lova
kia
Sw
ed
en
Ge
rma
ny
Ire
lan
dL
ith
ua
nia
Po
rtu
ga
lB
elg
ium
Fra
nce
Fin
lan
dE
U2
8H
un
ga
ryC
yp
rus
Cro
atia
Esto
nia
Po
lan
dR
om
an
iaIt
aly
Gre
ece
Bu
lga
ria
La
tvia
%
Poorest
Average
Richest
Unmet need is an indicator of insufficient
spending and ineffective policiesUnmet need for a medical examination for financial or other reasons by income groups in the European Union,
EU-SILC data for 2013
Households not protected against the
cost of ill health
Impoverishing
health
expenditure
Catastrophic health
expenditure
Why more public and
less out-of-pocket spending
on health?
Countries with higher OOPs have
more catastrophic spending
Czech Republic
Estonia
Georgia
Greece
Ireland
Latvia
Moldova
Portugal
Slovenia
R² = 0.44
0
2
4
6
8
10
12
14
16
18
0 10 20 30 40 50 60 70
% p
op
ula
tio
n w
ith
ca
tas
tro
ph
ic s
pe
nd
ing
OOPs as % of total spending on healthSource: WHO 2015
But policies matter too!
Where OOPs are <15% of total health spending, very few households experience catastrophic spending
Cyprus
Weak financial protection of the
health system leads to more poverty
0%
2%
4%
6%
8%
10%
12%
14%
16%
MDA 2013 LVA 2013 GEO 2014 POR 2010 LTU 2012 GRC 2013 EST 2012 CZE 2012 IRE 2009 SVN 2012
Further impoverished
Impoverished
At risk of impoverishment
Catastrophic OOPs
Source: WHO Barcelona Office for Health Systems Strengthening 2016
Incidence of catastrophic and impoverishing out-of-pocket payments (OOPs) in Europe
Distribution matters: the poorest households are consistently
at greatest risk – important note for policy responses
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
SV
N 2
007
IRL 2
009
CZ
E 2
009
CY
P 2
009
GR
C 2
008
LV
A 2
008
ES
T 2
007
PR
T 2
005
LT
U 2
008
1 (poorest) 2 3 4 5 (richest)
Source: WHO 2015
Consumption quintiles:
Monitoring financial protection over time in Latvia:
Putting the analysis in context of policy changes
10.0% 10.1%10.6%
12.9%
0%
2%
4%
6%
8%
10%
12%
14%
2008 2009 2010 2013
Share
ofhousehold
s
At risk of impoverishmentafter OOPs
Impoverished after OOPs
Further impoverishedafter OOPs
Catastrophic OOPs
Source: WHO Barcelona Office for Health Systems Strengthening 2016
Co-payment exemptions discontinued for the poor in 2011
Catastrophic spending is primarily due to co-payments for
medicines in Latvia: consistent with findings in most countries
0
10
20
30
40
50
60
70
80
90
100
1 (poorest) 2 3 4 5 (richest)
Inpatient care
Diagnostic tests
Dental care
Outpatient care
Medical products
Medicines
Source: WHO Barcelona Office for Health Systems Strengthening 2016
More public spending means lower
burden on patients, but policies matter
Source: WHO estimates for 2012, selected countries with population > 600,000
More public spending and better health policies
15%
6%
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75F
ran
ce
UK
Luxe
mb
ou
rgC
roa
tia
Slo
ven
iaG
erm
any
De
nm
ark
No
rwa
yS
we
de
nC
ze
ch R
ep
Austr
iaIc
ela
nd
Ire
land
Belg
ium
Fin
land
Esto
nia
Italy
Slo
vakia
Pola
nd
Spa
inH
ung
ary
Sw
itze
rla
nd
Port
ug
al
Isra
el
Ma
lta
Lithu
ania
Gre
ece
Latv
iaR
ussia
n F
ed
Cyp
rus
Tu
rke
yR
om
ania
Bosn
ia &
He
rzB
ela
rus
Tu
rkm
en
ista
nS
erb
iaT
FY
RM
Mo
nte
neg
roB
ulg
aria
Kaza
kh
sta
nA
lban
iaA
zerb
aija
n
Mo
ldova
Kyrg
yzsta
nU
zb
ekis
tan
Ukra
ine
Arm
en
iaG
eo
rgia
Ta
jikis
tan
Out-of-pocket payments (OOPs) as a % of total spending on health(high, upper-middle and lower-middle income countries)
Source: WHO data for 2014
Danger zone >30%
Warning 15-30%
Safe <15%
Source: WHO data for 2012
0%
2%
4%
6%
8%
10%
12%
Aze
rba
ija
n
Tu
rkm
en
ista
n
Ge
org
ia
Ta
jik
ista
n
Arm
en
ia
Ka
zak
hst
an
Alb
an
ia
Uzb
ek
ista
n
Cy
pru
s
Latv
ia
Ru
ssia
n F
ed
Be
laru
s
Ro
ma
nia
Uk
rain
e
Bu
lga
ria
Ky
rgy
zsta
n
Mo
nte
ne
gro
TF
YR
Ma
ced
on
ia
Isra
el
Tu
rke
y
Po
lan
d
Lith
ua
nia
Est
on
ia
Hu
ng
ary
Ire
lan
d
Mo
ldo
va
Slo
va
kia
Cro
ati
a
Po
rtu
ga
l
Gre
ece
Se
rbia
Slo
ve
nia
Cze
ch R
ep
ub
lic
Fin
lan
d
Sw
itze
rla
nd
Bo
snia
& H
erz
Sp
ain
Ita
ly
No
rwa
y
UK
Sw
ed
en
Be
lgiu
m
Ge
rma
ny
Au
stri
a
Fra
nce
De
nm
ark
Ne
the
rla
nd
s
Ge
ne
ral
Go
ve
rnm
en
t H
ea
lth
Ex
pe
nd
itu
re (
%G
DP
), 2
01
2Public spending on health as a share of GDP
WHO/EUROPE countries with population > 600,000 (2012)
0% 2% 4% 6% 8%
Low & lower-middle income
Upper-middle income
High income
Minimum 6% for good
financial protection(provided that strong pro-poor policies are
also in place)
Accounting for public spending on health:
the equation and a simple illustration
Gov’t health spending
GDP=
Total gov’t spending
GDPX
Gov’t health spending
Total gov’t spending
Fiscal context Public policy
priorities
Government
health spending
as share of the
economy
6% 12-15%40-50%
Priority to health in public spending: a political choiceShare of health spending within government budget (high, upper-middle, lower-middle and low income)
0
2
4
6
8
10
12
14
16
18
20
22
Cypru
s
La
tvia
Ru
ssia
n F
ed
era
tion
Isra
el
Pola
nd
Gre
ece
Esto
nia
Bulg
aria
Fin
land
Irela
nd
Port
ug
al
Lithu
ania
Slo
ven
ia
San M
arin
o
Ma
lta
Lu
xe
mbo
urg
Ita
ly
Czech R
epu
blic
Slo
vakia
Belg
ium
Spain
Cro
atia
Sw
ede
n
Icela
nd
Fra
nce
Un
ite
d K
ing
dom
De
nm
ark
Austr
ia
No
rwa
y
Mo
naco
Germ
any
Ne
therl
and
s
Sw
itzerl
and
Aze
rbaija
n
Turk
men
ista
n
Alb
ania
Mo
nte
neg
ro
Hu
nga
ry
Kazakhsta
n
Ro
man
ia
Turk
ey
Bela
rus
Serb
ia
TF
YR
M
Bosnia
an
d H
erz
eg
ovin
a
Geo
rgia
Arm
enia
Uzbe
kis
tan
Ukra
ine
Kyrg
yzsta
n
Re
pub
lic o
f M
old
ova
Tajik
ista
n
Source: WHO Global Health Expenditure Database for 2012
Minimum
12%
Share of health within government budgets
over time: a widening gap
Source: WHO NHA database, 2012
14.4%13.7%
Spending on health and
financial protection:
why and how?
Conclusions
Why? Some starting points
Improve health
outcomes
Reduce poverty
due to ill health
Break the vicious
cycle between
poverty and ill
health
Improve economic
and social
development
How? Some key indicators
Aim for reducing OOPs to 15% of THE - Focus on medicines: the single most important factor for catastrophic expenditure
0% impoverishment - Focus on the poor and pensioners
Aim for at least 6% of GDP public spending on health
Allocate minimum 12% of government spending to health
15%
0%
6%
12%
Universal health coverage (UHC)
All people should get access to
needed health services of
sufficient quality to be
effective (incl. prevention,
promotion, treatment,
prescription medicine, rehabi-
litation and palliative care)
without the risk of being
exposed to financial hardship
Our vision in WHO is a Europe free of
impoverishing out-of-pocket payments
0%A vision that originates from the Tallinn Charter
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