Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 1 |1 | + + David B Evans, Director.

Session 5: From Universal Access to Universal Health CoverageHIV and Health Systems Pre-Conference Meeting, Vienna

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+ +

David B Evans, DirectorHealth Systems FinancingDavid B Evans, Director

Health Systems Financing

Financing for Universal Coverage:Financing for Universal Coverage:

Are there Generalizable Lessons from Are there Generalizable Lessons from Experience?Experience?


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OUTLINEOUTLINEOUTLINEOUTLINE

1. Health systems financing and universal coverage: what do we mean?

2. Where are we now and why?3. Moving towards universal coverage


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Universal Coverage and FinancingUniversal Coverage and FinancingUniversal Coverage and FinancingUniversal Coverage and Financing

World Health Assembly Resolution 58.33, 2005:

Urged countries to develop health financing systems to:

Ensure all people have access to needed services

Without the risk of financial catastrophe linked to paying for care

Defined this as achieving Universal Coverage


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Two components of Two components of CoverageCoverage Two components of Two components of CoverageCoverage

1. Coverage with needed services

2. Coverage with financial risk protection


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World Health Report 2010 World Health Report 2010

Health Systems Financing: the Path to Universal Health Systems Financing: the Path to Universal CoverageCoverage

To be launched on 22 November 2010

Builds on WHO Constitution; Alma Ata and Health for All; WHR2008 on Primary Health Care


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OUTLINEOUTLINEOUTLINEOUTLINE




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Percentage of births by medically trained persons Percentage of births by medically trained persons - DHS- DHS

Percentage of births by medically trained persons Percentage of births by medically trained persons - DHS- DHS

02

04

06

08

01

00

0 10 20 30 40 50

Q1Q5 Average

Source: Latest available DHS for each country (excl. CIS countries)

Q1, Q5 and Average - 22


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Overall coverage and level of inequity differ by types of services

Generally access to delivery by medically trained person more inequitable than vaccination services

05

01

00

1 2 3 4 5

MAR, 2004

SBA DTP

Measles

Pe

rce

nta

ge

quintile

Graphs by code and year

05

01

00

1 2 3 4 5

KHM, 2000

SBA DTP

Measles

Pe

rce

nta

ge

quintile

Graphs by code and year

Patterns of exclusion: Delivery by a medically trained person (SBA), Patterns of exclusion: Delivery by a medically trained person (SBA), DTP3 (DTP) and MCV (MCV) – from DHSDTP3 (DTP) and MCV (MCV) – from DHSPatterns of exclusion: Delivery by a medically trained person (SBA), Patterns of exclusion: Delivery by a medically trained person (SBA), DTP3 (DTP) and MCV (MCV) – from DHSDTP3 (DTP) and MCV (MCV) – from DHS


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1,300

150 100

0

500

1,000

1,500

Household categories

Popu

lati

on in

mill

ions HH without access to

affordable and effectivehealth care

HH with catastrophichexp

HH impoverished

Lack of access, financial catastrophe and impoverishment Lack of access, financial catastrophe and impoverishment due to OOPsdue to OOPs


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What role does health systems financing play? What role does health systems financing play?

Three inter-related explanations linked to health system financing

1. Insufficient funds for health in some settings

2. Too much reliance on direct out-of-pocket payments to finance health – limited financial risk protection

3. Inefficiency and inequity in use of resources


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Insufficient Funds Insufficient Funds

Calculations for the high level Task Force on Innovative International Financing for Health Systems:

A set of essential services that includes HIV prevention and treatment, and the accompanying health systems development for all interventions – average of $42 per capita (unweighted) in 49 low-income countries in 2009, rising to $65 in 2015

31 of them spent less than $31 per capita per year 2008. Only 8 have any chance of reaching the required funding from domestic sources by 2015


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OUTLINEOUTLINE




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SolutionsSolutions

1. Raise sufficient funds (or diversify sources in higher income countries)

2. Reduce reliance on direct OOPs, increase prepayment and pooling to increase financial risk protection

3. Improve efficiency and equity in use


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Selected actions for global community to support countries raise funds

Selected actions for global community to support countries raise funds

Donor and lending institutions agree to mechanisms to ensure predictable, stable, increased flows for health – and keep promises.

Donors and lending institutions fund priority activities included in PRSPs, SWAPs, or strategic plans - or provide budget support to government. Recipient govts should decide priorities rather than donors


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Actions for Global Community in Supporting Financial Risk Protection

Actions for Global Community in Supporting Financial Risk Protection

Channel external funds through existing or nascent institutions for pooling funds rather than bypassing them e.g. Rwanda.


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Actions for Global Community in Supporting Improving Efficiency

Actions for Global Community in Supporting Improving Efficiency

Reduce fragmentation and transaction costs, particularly in the way external funds are channeled and with application and reporting – Estonia for HIV and drug users; Kyrgyzstan for TB funding. Rwanda permanent secretary reported at WHA2010 that Rwanda has to report on 890 different health indicators to the various donors, almost 600 for HIV and TB alone. Vietnam had 400 aid missions to review health projects in 2009.

Practice what we preach – get more efficient at global level rather than continually introducing more fragmentation, more secretariats – now more than 140 global health initiatives of various types


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ConclusionsConclusions

Globally still a long way from universal coverage

Solutions are pretty obvious in the big picture – raise enough funds; reduce OOPs and increase prepayment and pooling; improve efficiency and equity

The technical ways to do this are pretty clear as well – is it that the willingness lags behind the technical knowledge


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Spare slideSpare slide


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Hard Choices


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Heavy reliance on direct paymentsHeavy reliance on direct paymentsCountries & Shares of Total Health Expenditure from Out-Countries & Shares of Total Health Expenditure from Out-

of-Pocket Payments (2006)of-Pocket Payments (2006)

Out-of-pocket payments as % of total health expenditure

AFR

<10%

3

10-20%

9

20-30%

8

30-50%

16

>=50%

10

Global*

<10%

18

10-20%

40

20-30%

46

30-50%

51

>=50%

37

*excl Somalia


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Inefficiency: Some countries obtain higher levels of Inefficiency: Some countries obtain higher levels of health and coverage for the same expenditure health and coverage for the same expenditure

Inefficiency: Some countries obtain higher levels of Inefficiency: Some countries obtain higher levels of health and coverage for the same expenditure health and coverage for the same expenditure

10

100

1,000

60 62 64 66 68 70 72 74 76 78 80

Life expectancy (years)

To

tal

he

alt

h e

xp

en

dit

ure

pe

r c

ap

ita (

US

$,

20

06)

India

Thailand

China

Uzbekistan

Sri Lanka

Viet Nam

RussiaTurkey

Colombia

Peru

Brazil

Egypt

Bangladesh

Cost RicaCuba

UruguayMexico Chile

Kuwait

Comoros

Palau

Namibia

Hungary

Turkmenistan

Seychelles

Czech RepublicCroatia

Grenada

Latvia

Jordan

Haiti

Nauru

Marshall

Trinidad & Tobago

Kazakhstan

Tuvalu

Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 1 |1 | + + David B Evans, Director.

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