Health Systems Performance and Universal Health Coverage

Transcription

1 Health Systems Performance and Universal Health Coverage David B Evans, Director Health Systems Financing World Health Organization, Geneva 1

2 Outline 1.Universal Health Coverage What is it? How to move closer? How to measure progress? 2. Link with Health System Performance Assessment? 3.Implications for the post-2015 agenda 2

3 Universal health coverage is the single most powerful concept that public health has to offer Dr Margaret Chan, Address to the Sixty-fifth World Health Assembly, May

4 WorldHealth Report2010 4

5 WorldHealth Report

6 Formal Definition of Universal Coverage World Health Assembly Resolution 58.33, 2005: Urged countries to develop health financing systems to: Ensure all peopleobtain the health services they need Without the risk of financial ruin linked to paying for care out-of-pocket Defined this as achieving Universal Coverage: coverage with health services; with financial risk protection; for all 6

7 Universal Health Coverage 7

8 Universal Health Coverage: Features 1. Health services: prevention, promotion, treatment, rehabilitation, palliative care not just treatment 2. Coverage with services of good quality "effective coverage" 3. UHC is a journey: New technologies Increasing costs Increasing population or changing in population age structure Changing disease patterns 8

9 Millions miss out on needed health services Percentage of births by medically trained persons Q1, Q5 and Average Q5 Q1 Average Source: Latest available DHS for each country (excl. CIS countries) 9

10 Millions more suffer financially when they use health services EMR AFR impoveris hment catas trophic EUR SEA AMR WPR Number of people (million) 10

11 Moving Closer to UHC: Requirements Universal access to essential medicines and health products Sufficient motivated health workers, of appropriate mix, located close to people Appropriate infrastructure Good health governance People-centered, integrated health services based on primary health care, focusing on all priority health problems including current MDGs Appropriate health financing systems 11

12 Three Fundamental Health Financing Challenges for Achieving Universal Coverage 1. Raise sufficient funds for health; 2. Ensure/maintain financial risk protection i.e. ensure that financial barriers do not prevent people using needed health services nor lead to financial ruin when using them; 3. Minimize inefficiency and inequity in using resources. 12

13 2010 Health Expenditure per Capita (US$) (data updated March 2013) p.c. THE p.c. GGHE p.c. GDP Country Group (US$) (US$) (US$) African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Total

14 Still Insufficient Resources for Health in many countries: 2010 Total health expenditure, per capita, 2010 total low income* low middle income* < 20$ $ $ $ $50 - $100 per capita required to attain health MDGs * World Bank Income group classification, May 2013 Excluding Somalia, DPR Korea, Zimbabwe 14

15 1. Raising sufficient Funds: Domestic Options 1. Increase priority for health in budget allocations (45 governments devote less than 8% of their spending to health, and 14 devote less than 5%) 15

16 Trends in GGHE (% GGE) by Region (un-weighted average) General government expenditure on health % General government expenditure (GGE) African Region Americas Region Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region

17 Diversified Domestic Funds Resource taxes: Botswana, PNG, Lao PDR Financial transactions tax for health: Argentina, Brazil, Zambia. (India could raise US$ 370 million per year from a very small levy (0.005%) & Gabon raised $30 million for health in 2009 partly by imposing a 1.5% levy on companies handling remittances from abroad). Luxury Taxes: China, Bulgaria, Viet Nam Mobile Phones or Telecommunications: Philippines,Uganda, Gabon, Ghana, Republic of Congo and Senegal Tobacco and alcohol: many countries Sugary drinks: Iran VAT:Ghana, Chile Progressive: payroll tax Kazakhstan, income levy for AIDS Zimbabwe 17

18 2. Increase or maintain financial risk protection Reduce out of pocket payments at the point of service Increase "prepayment" through health insurance and/or taxes with pooling 15-20% OOPs/Total Health Expenditure Recent experience in Brazil, Chile, China, Colombia, Costa Rica, Ghana, Kyrgyzstan, Mexico, Republic of Moldova, Rwanda, Thailand, Turkey and Sierra Leone show that major advances can be made even in low-and middle-income countries. 1. Community and micro insurance have not proved capable of being financially sustainable pools too small. 2. It is difficult to ensure universal coverage without making contributions (taxes and/or insurance) compulsory. 3. There will always be poor who cannot contribute and must be subsidized from pooled funds generally from tax revenues 18

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20 3. Reduce Inefficiency 20

21 Common Forms of Inefficiency 10 common causes of inefficiency including: Spending too much on medicines and health technologies, using them inappropriately, using ineffective medicines and technologies Leakages and waste, again often for medicines Hospital inefficiency particularly over-capacity De-motivated health workers, sometimes workers with the wrong skills in the wrong places Inappropriate mix between prevention, promotion, treatment and rehabilitation, or between levels of care If all types are present, efficiency gains would effectively result in increasing the available funds for health by 20-40%. i.e. substantially more health for the moneycould be obtained by reducing inefficiency 21

22 UHC Measuring Progress Inputs & processes Outputs Outcomes Impact Health Financing Health workforce Infrastructure Information Governance Service Delivery Service access and readiness Service quality and safety Service Utilization Prepaid funds Coverage of interventions Coverage with a method of financial risk protection Risk factors Health status Household financial wellbeing Responsiveness Level and distribution (equity) Social Determinants 22

23 Financial Risk Protection: Impact Indicators. Number of countries with at least 2 data points Incidence of catastrophic health expenditure due to out-of-pocket payments Mean positive overshoot of catastrophic payments Incidence of impoverishment due to out- of-pocket payments Poverty gap due to out-of-pocket payments

24 Catastrophic health expenditure -from various household surveys Q1, Q5 and Average - Catastrophic health expenditure Percentage of households Source: Household surveys, 95 countries Q5 Q1 Average

25 25 Catastrophic health expenditure - European Region of WHO Q1, Q5 and Average - Incidence of catastrophic health expenditure 0% 5% 10% 15% Percentage of households LUX CZE GBR SVN DNK BEL IRL SWE AUT HRV NOR ISR ISL ESP BLR FIN CHE ITA TUR HUN FRA UKR LTU BGR GRC KGZ KAZ ARM PRT LVA EST ALB TJK MDA GEO RUS AZE Q1 Q5 Average

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27 Service Coverage: Intervention areas and tracer indicators Intervention area Child vaccination. Maternal care Examples of tracer indicators DPT3/penta, measles; fully vaccinated children Antenatal care(4+ visits); skilled birth attendance; postnatal care Family planning Met need for FP Treatment of sick children Sick children receiving correct treatment (suspected pneumonia, diarrhoea, malaria) Malaria TB HIV prevention ITN ownership /sleeping under ITN; IPT during pregnancy TB cure rate among estimated cases PMTCT among HIV positive women; ART among adults and children Cancer HPV vaccination; cervical cancer screening; non-use of tobacco Cardiovascular diseases Chronic adult conditions Injuries 27 Other NCD Normal BP among those in need of hypertension treatment Arthritis treatment; depression treatment; vision correction Injury treatment Cataract surgery coverage

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29 Outline 1.Universal Health Coverage What is it? How to move closer? How to measure progress? 2. Link with Health System Performance Assessment? 3.Implications for the post-2015 agenda 29

30 Main Social Goals to Which Health Systems Contribute Health Responsiveness Financial Contribution LEVEL x x DISTRIBUTION x x x Efficiency Quality Equity 30

31 HSPA Measurement Health: Healthy Life Expectancy (HALE) Responsiveness: Respect for Persons and Client Orientation Fairness of financial contributions index 31

32 Attainment and Performance 1.Attainment = achievement of goals -singly and composite attainment. Weights from a web-based survey 2.Performance (Efficiency) -attainment related to resources available and other non-health system inputs to the production of health system outcomes 3.Separate efficiency (performance) index for health, and for the composite goal 32

33 efficiency = b/(b+c) 33 inputs

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35 Functionsof healthsystems Financing Revenue collection S t e w a r d s h i p Fund pooling Purchasing Provision Personal health services Non-personal health services Resource generation 35

36 UHC and HSPA 1.HSPA focused mostly on impacts health system has only limited effect 2.UHC focuses on "instrumental" goals what health system can do 3.Efficiency calculations more important in HSPA. Measurement secondary in UHC much more policy oriented, including ways to improve efficiency 36

37 UHC Measuring Progress Inputs & processes Outputs Outcomes Impact Health Financing Health workforce Infrastructure Information Governance Service Delivery Service access and readiness Service quality and safety Service Utilization Prepaid funds Coverage of interventions Coverage with a method of financial risk protection Risk factors Health status Household financial wellbeing Responsiveness Level and distribution (equity) Social Determinants 37

38 Outline 1.Universal Health Coverage What is it? How to move closer? How to measure progress? 2. Link with Health System Performance Assessment? 3.Implications for the post-2015 agenda 38

39 2010 MDG Summit Rio+20 Parallel, Intersecting Processes Mandated the Post-2015 Development Agenda Mandated for the SDGs Member States SG s High Level Panel of Eminent Persons on Post Development Agenda (HLP) Member States Intergovernmental Open Working Group on SDGs (OWG) Other UN System UN Task Team (UNTT) Working Groups UNDG MDG Task Force Consultations UN System UNTT Technical Support Team on SDGs Thematic collaborations Civil Society Sustainable Development Solutions Network (SDSN) Informal Coordination Group: DESA-ASG (Shamshad Akhtar), UNDG/UN Women-ASG (John Hendra), SG Special Advisor on Post-2015 (Amina Mohammed) Civil Society Multi-stakeholder advisory group on SDGs (MAG), TBC HLP and OWG reports to 68 th UNGA

40 WHO's Perspective: Health and Sustainable Development How should progress in improving human health be reflected in a future set(s) of development goals? Health is central to sustainable development (SD) Input Outcome Measure Health is a precondition Health is a beneficiary Health is therefore an indicator of progress Health as a Goal Health as an Indicator 40

41 Universal Health Coverage: An Overarching Health Goal Allows incorporation of all current health goals and targets into one umbrella health goal Links to poverty reduction and economic wellbeing 41

42 UHC: Rationale Coverage with health services helps improve and maintain health/avert disease (instrumental goal) Financial risk protection helps to increase coverage with needed services (instrumental goal) BUT: UHC is valued for its own sake as well (intrinsic goal) People sleep well at night knowing that health services they might need to use are available, of good quality, and affordable 42

43 Practical Considerations 1. How to express the goal 2. What service coverage and quality tracers are in the global set? 3. Should there be a UHC index? Back to some of the problems of the 2000 HSPA exercise 43

44 40% catastrophic spending threshold MDG: pop Source: Wagstaff WB Prot. against impoverishment: poorest 40% MDG: poorest 40% Prot. against impoverishment: pop Non-MDG: pop Prot. against cata. payments: poorest 40% 80 Non-MDG: poorest 40% 100 Prot. against cata. payments: pop 44 eap eca lac mna sar ssa MDG: Treatment of ARI, diarrhea, malaria, and TB; voluntary counseling and testing for HIV; full immunization; 4+ antenatal visits; skilled birth attendance. Non-MDG: Care within 30 mins of traffic accident and non-traffic accident; treatment of angina, arthritis, asthma, dental problems, depression, diabetes, and mental illness; mammogram; pap smear; cataract removal. Prot. against University cata. payments of Canberra, - % 16 population August 2013 not spending >40% of nonfood consumption on health care. Prot. against impoverishment - poverty gap (using $1.25-a-day PL) in a world without OOPs as % of actual poverty gap.

45 Thank you 45

46 spare slides 46

47 Global Level Tracer Conditions? Antenatal care: 4+ visits Birth attended skilled health personnel Measles, DTP3, Hib3, HepB3 Children < 5: ARI visit; sleeping under ITN; ORT diarrhoea ART HIV; MCTC HIV + pregnant women TB: case detection rate Cervical cancer screening women Tobacco use among adults (reflects coverage and effectiveness of tobacco prevention interventions) Additional as possible 47

48 Source: The World Bank, World Development Indicators Database 48 48

49 General government expenditure (GGE) as a share of GDP and GGE per capita (GGE/cap) in US$, GGE/GDP GGE/cap Source: The World Bank, World Development Indicators Database 49 % Banglad Madaga Uganda Central Ethiopia Cambodia Nepal Guinea- Sao Benin Mali Togo Côte Zambia Comoros Sierra Pakistan Niger Myanmar Lao PDR Burkina Gambia Ghana Tajikistan Rwanda Senegal Malawi Kenya Republi United Guinea Mozam Papua Mauritania Uzbekis Haiti Vietnam Solomo Chad Liberia Eritrea Democr Nigeria Burundi Afghani GGE/cap US$

50 General government health expenditure (GGHE) as a share of GGE and GGHE per capita, % 20.0% GGHE/GGE GGHE/cap % 10.0% US$ current 5.0% % 0 Source: The World Bank, World Development Indicators Database 50 50

51 Source: WHO and The World Bank 51 51

52 Current MDGs eradicating extreme poverty and hunger; achieving universal primary education, promoting gender equality and empowering women reducing child mortality rates, improving maternal health, combating HIV/AIDS, malaria, and other diseases, ensuring environmental sustainability, and developing a global partnership for development. [1] 52

53 Post MDGs Achieve universal primary education health coverage Possible Targets: Reduce maternal mortality by xxx Child health HIV/AIDS, TB, malaria NCDs Reduce impoverishment due to out of pocket payments in health by 50% 53

54 EFFICIENCY INDEX ifrontier production function - attainment a function of health expenditure per capita, average years of schooling itranslog production function, fixed effects, Yit = αi + β 1X 1it + β 2X 2it + β 3( X 1it) + β 4( X 2it) + β 5( X 1it)( X 2it) + v Other determinants of efficiency in a second stage analysis 54

55 Quality Indicators (Output). Table 3: Quality Retention on antiretroviral therapy at 12 months 92 3 Proportion of children initially breastfed (within 80 one hour of birth) Avoidable asthma admission rates 28 In-hospital case-fatality rates within 30 days after admission for ischemic stroke 27 Postoperative pulmonary embolism or deep vein thrombosis Schizophrenia re-admissions to the same hospital Percentage of women aged screened for breast cancer