Health Financing Note East Asia and Pacific (EAP) Region Governance issues in resource transfer March 2010
Stewardship of financing (governance, regulation and provision of information) The population Investing in Health and Thinking about HF Flow of Funds and Functions for Health Financing Provision of services Health services Cost sharing/user fees Purchasing of services Coverage Choice? Pooling and Management of funds Coverage Choice? Collection of funds Entitlement? Contributions Source: WHO, 2006. 2
5 Governments: Health Not High Priority (in part due to relatively low revenue base) Government health spending vs income, 2005 10 15 Japan Cambodia Lao PDR Mongolia China Vietnam Philippines Indonesia Samoa Korea, Rep. Thailand Malay sia Singapore Taiwan, China Hong Kong, China Source: WDI Note: log scale 250 1000 5000 25000 GNI per capita, US$ 3
Cambodia China Fiji Indonesia Korea, Rep Lao PDR Malaysia Mongolia Philippines Samoa Thailand Tonga Vietnam High Reliance on OOPs as a Result 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Direct Tax Indirect Tax Non-tax Revenue Social Health Insurance Private Insurance OOPs Other 4
Social Security Expenditures on Health as % of THE Move to Insurance? Social Security and General Governmnet Expenditure on Health-EAP Countries 25% CHN MNG 20% 15% 10% VNM PHL IDN THA 5% LAO KHM WSM TLS MYS VUT FJI TON PNG SLB 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5 Government Expenditure on Health (less Social Security) as % of THE
Social Security Expenditures on Health as % of THE Use of HI: Less than Other Regions of World 40% 35% Social Security and General Government Expenditure on Health- LMIC Regional Averages (2005) ECA 30% 25% 20% 15% LCR 10% MNA 5% SAR EAP 0% AFR 0% 10% 20% 30% 40% 50% 60% 70% General Government Expenditure on Health (less Social Security) as % THE 6
And Social Health Insurance Complex Activities & Takes Time Capacity? Collection Pooling Benefits Package Contracts Payment Systems MIS systems Claims Processing Quality Assurance Regulations Forecasting 16 14 12 10 8 6 4 2 0 Years to Fully Implement Estonia Romania Kyrgz Albania Russia 7
Pooling Big challenge in the region Multiple pools China, Indonesia, Lao, Cambodia, Thailand, Vietnam, Mongolia Lowers Spreading of Risks (Equity) Lowers Leverage of Purchasers (Efficiency) Increases Administrative Costs (Efficiency) required household contribution required household contribution lower risk lower risk higher risk higher risk before risk pooling (only OOPS) after risk pooling (one possibility) 8
Lesson of South Korea: 380 to 1: Admin Costs as % of Payments 12 10 10 8.8 8.7 8 7.1 7 6 4 4.4 5 4 2 0.9 6 0.7 0.4 0 19 9 4 19 9 7 19 9 8 19 9 9 2000 2001 2002 2004 2005 2006 9
Mixed Incentives: Thailand 2001 >50 yrs. 1990 UC CSMBS SSS Contribution TAX 48 mil. 7 mil. 7 mil. NHSO MOF Comptroller SSO Capitation DRG FFS Capitation DRG Public Private Providers Services Insurees, Right holders 10
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Purchasing: FFS Predominates 12
Organization of Care and Governance Autonomization, Informal Payments, Dual Practice, Lack of Voice, Coordination of Sectors, Medical Tourism S hare of Informal Payments Among Users in Health S ervices (%) 90% 80% 70% 60% 50% 55% 74% 43% 81% 40% 30% 20% 10% 2% 0% Cambodia (2000) China (2001) Indonesia (2001) Thailand (2000) Vietnam (1992) 13
Assessing Performance Distribution of Public Subsidies for Hospital and Non-hospital Care (Concentration Indices) 0.6 0.4 0.2 0.0-0.2-0.4 Hong Kong, China Malaysia Thailand Vietnam Gansu, China Heilongjiang, China Indonesia Inpatient Outpatient Non-hospital care Total public subsidy 14
Other Analytic Work in Region Public Expenditure reviews (Laos) Including benefit-incidence analysis Civil Service Reform study across sectors Laos Governance and Health Cambodia Poverty and Health Studies Mongolia Health Financing Policy Notes (China) Rural Health (China) Decentralization and HF (Indonesia) Topical Regional Workshops Health Financing Feb 2008 in BKK Vulnerability Workshop June 2008 in BKK included focus on health sector Drawing on workshop an overview paper on health and vulnerability has been drafted will be distributed in Spring Impact Evaluation of new programs (Manila, December 2008) 15
Country-Specific Work Laos PDR Ongoing analytic work on health financing Review of health financing arrangements and support to government to develop health financing strategy Study of CBHI (determinants of enrollment and impact on utilization and OOPs) jointly with WHO Study of Social Health Insurance scheme (enrollment and non-enrollment of firms) jointly with WHO Qualitative study to understand low utilization of curative and preventive services Work on HF in Health Services Improvement Project Piloting of health equity funds (also in Cambodia) Thailand Universal Coverage scheme Sustainability/impacts under financial downturn Harmonization across schemes 16
EAP Observatory Work to date Objective Knowledge sharing Strengthen data systems for comparative analysis In-depth analysis on countries and issues WHO (WPRO) Products initiation HiTs and Policy Briefs Thailand? Institutional Framework One or many? Bank and other donors AUSAID, governments (NZ, Korea, etc) SEARO and Bank SA Region??? 17
5 5 25 Infant mortality rate 25 Outcomes Good Relative to Level of Economic Development 100 250 Cambodia Lao PDR Infant mortality vs income, 2005 100 250 Infant mortality rate vs health spending, 2005 Lao PDR Cambodia Mongolia Indonesia Philippines Samoa China Vietnam Mongolia Indonesia Philippines China Vietnam Samoa Malay sia Thailand Thailand Malay sia Korea, Rep. Taiwan, China Korea, Rep. Taiwan, China Source: WDI Note: log scale Singapore Hong Kong, China 250 1000 5000 25000 GNI per capita, US$ Japan Singapore Japan Hong Kong, China 5 25 250 1000 5000 Health expenditure per capita, US$ Source: WDI Note: log scale 18
-3-2 -1 0 1 2 3 Above average Below average Child (< 5 years) Mortality Child mortality relative to income & health spending, 2005 Vietnam Cambodia Samoa Lao PDR Mongolia Japan China Taiwan, China Korea, Rep. Malay sia Philippines Indonesia Singapore Thailand Hong Kong, China Above average Below average -3-2 -1 0 1 2 3 Perform ance relative to incom e Source: WDI 19
-.4 -.2 Below average 0 Above average Life Expectancy.2.4 Life expectancy relative to income & health spending, 2005 Philippines Indonesia Vietnam Lao PDR Malay sia China Mongolia Thailand Singapore Samoa Hong Kong, China Korea, Rep. Japan Taiwan, China Cambodia Below average Above average -.4 -.2 0.2.4 Perform ance relative to incom e Source: WDI 20
0 Maternal mortality rate 1000 2000 3000 Maternal Mortality: More Mixed Deliveries at home and deliveries without skilled attendants Maternal mortality rate vs income, 2005 Complex array of socioeconomic, environmental, and cultural factors that contribute to high maternal mortality Low social status of women Malnutrition Unequal access to health care resources Source: WDI Lao PDR Cambodia Indonesia Philippines Vietnam Thailand Mongolia China Malay sia Taiwan, China Korea, Rep. 250 1000 5000 25000 GNI per capita, US$ Singapore Japan Hong Kong, Chin 21
Changing Demographic and Disease Profile ST Demographic Dividend; LT Aging and NCDs Ages 75+ 70-74 65-69 60-64 55-59 50-54 45-49 40-44 MALES FEMALES 2020 35-39 30-34 2000 25-29 20-24 15-19 10-14 5-9 0-4 100000 80000 60000 40000 20000 0 20000 40000 60000 80000 100000 Source: World Bank 22
Expected Increases in Health Expenditures from Years 2000-2020 Due to Population and Epidemiologic Dynamics 80% 70% Change in total pop. + aging factor Change in total pop. 60% 50% 40% 30% 20% 10% 0% -10% 23
GDP per Capita, PPP Health Expenditure per Capita, current US$ Health Expenditures GDP per Capita and Health Expenditure per Capita, 2005 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - ECA LAC MNA EAP SAR AFR 350 300 250 200 150 100 50 - GDP per Capita, PPP Health Expenditure per Capita, Current US$ 24
5 10 15 EAP Countries Not Big Spenders for Health Total health spending vs income, 2005 Japan Cambodia Vietnam China Mongolia Lao PDR Philippines Korea, Rep. Taiwan, China Hong Kong, China Samoa Malaysia Thailand Singapore Indonesia Source: WDI Note: log scale 250 1000 5000 25000 GNI per capita, US$ 25