Universal health coverage A review of Commonwealth hybrid mixed funding models

Transcription

1 Universal health coverage A review of Commonwealth hybrid mixed funding models Dr Ravi P. Rannan-Eliya Institute for Health Policy, Sri Lanka Global Network for Health Equity (GNHE), Asia Network for Capacity Building in Health Systems Strengthening (ANHSS) Commonwealth Civil Society Forum Geneva 21 May, 2016 Hosted by

2 Universal Health Coverage (UHC) Shared global goal (SDG 3) Not only good health, but also arrangements that ensure everyone obtains the quality health services they need without financial hardship What does this mean? Everyone Minimizing disparities in use of care between rich and poor Needed quality health services Everyone obtains adequate amounts of quality healthcare Financial hardship Organizing health systems so that all people obtain health services without facing financial hardship from having to pay

3 The reality today in most developing countries is far from this

4 People don t obtain enough healthcare and the poor obtain less

5 Millions face financial hardship and poverty to obtain healthcare

6 What we usually tell governments to do 1. Increase public funding for health Either taxation or social health insurance 2. Improve the health infrastructure and availability of services 3. Reduce out-of-pocket spending on health

7 How? The established routes to Social health insurance with taxation Mandatory payroll contributions by workers and employers Tax subsidies to extend coverage to the poor Delivery usually by private services UHC National health service Government uses taxes to to pay for 80% or more of all healthcare Delivery usually by government services The modernized Bismarck model The Beveridge model 7

8 The Problem

9 It costs a lot of public money to follow Beveridge or Bismarck United Kingdom % of GDP Japan 1950s 3% of GDP Brazil, Turkey, Thailand 2000s 4-5% of GDP

10 5 Social health insurance funding by income category as share of GDP (%) Low-income Lower-middle income Upper-middle income High income

11 25 Government tax revenues by income category as share of GDP (%) Low-income Lower-middle income Upper-middle income High income

12 Reality is that neither the two usual routes to UHC are feasible in lower income nations

13 Country Comparison of Some Hybrid Systems with Better Known UHC Stars Public health spending (% GDP) Out-ofpocket funding (%) Skilled birth attendance (%) IMR Life expectancy Sri Lanka Malaysia Mauritius Mexico Jamaica Thailand Turkey Brazil

14 Comparison of Some Hybrid Systems with Better Known UHC Stars HIGH INCOME ECONOMIES Health system Public health spending (% GDP) Private funding (%) Skilled birth attendance (%) IMR Life expectancy Hong Kong Ireland Australia UK New Zealand

15 Do these hybrid mixed funding models have anything in common?

16 Their public schemes aim to be universal and comprehensive Universal Access is not based on income or means testing Strong emphasis on being free at point of use Strong emphasis on providing services close to people Comprehensive Do not explicitly confine services to essential or basic care Full range of services High priority given to expensive hospital care

17 Universal but in practice pro-poor in reach Typical developing country Hybrid system Poorest 40% Richest 40% Outpatient care 30 Typical situation in 24 developing countries with poor coverage 56 Poorest 40% Richest 40% Public Private Public Private

18 To balance their budgets and be pro-poor, they skimp on consumer quality, but not on clinical care Choice of doctors Time spent with doctor Amenities in public facilities Overcrowding, waiting times..

19 Relying on rich to voluntarily opt out and pay for care in private sector Use of public and private care by poor and rich Public Private 19 0 Poor Q2 Q3 Q4 Richest

20 A big package for some and a small one for others? 20

21 A decent package for everyone? But I don t want to pay!! 21

22 A no frills but full package for all Private sector 22

23 Caveat These systems are not perfect Middle class often unhappy and problem for political leaders But alternatives usually end up being too expensive

24 Recommendations

25 Relative mentions of hybrid models in recent publications Rwanda Brazil Turkey Thailand

26 Recommendations Hybrid or mixed funding models with roots in Commonwealth offer lessons on how to achieve UHC with limited fiscal resources 1. Concerted action to better document and understand these experiences 2. Collective effort to share the lessons not only within the Commonwealth but with rest of global community