What are the options for sustaining AIDS, TB and malaria programs after the donors pull out? Reflections from 7 South East Asian countries and China. Presented by David Collins of MSH at the 5th International Conference on Public Health among Greater Mekong Sub-Regional Countries, University of Public Health, Yangon, Myanmar, September 2013 1
Background MSH is a large non-profit dedicated to saving lives and improving the health of the world s poorest people by closing the gap between knowledge and action in public health. We work in more than 40 countries with funding from governments and foundations main funder is USG. David Collins has been with MSH for 25 years based in Boston, Kenya and South Africa. 2
MSH Health Care Financing Work Sustainable financing Social health insurance Performance-based incentives Financial planning and budgeting Cost modeling 3
Sustainable AIDS, TB and Malaria Programs Most developing countries are facing increasing costs for AIDS, TB and malaria (ATM) control as they continue to scale up services to meet the needs. Reductions in donor funding means that some countries must greatly increase their domestic financing for the ATM programs to ensure that they are sustainable. Even countries that are not yet facing reductions need to make sure their programs are cost-effective and efficient for them to be sustainable in the future. 4
Research Information on the financial sustainability of ATM programs was obtained from China, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand and Vietnam. The findings were discussed in April, 2013 at an international workshop attended by those countries in Jakarta supported by the Global Fund, USAID TB CARE I, the Indonesian MOH and MSH. 5
Comparison of ATM priorities, services and financing Country GDP per capita 2011 (US$) GFATM class Disease burden Formal service provision Programs presented Donor funding level and trend 1/ Current domestic financing 1/ Medium-term future domestic financing 1/ Malaria TB AIDS China 5,445 UM H S L Mostly public TB None/same Government and insurance Indonesia 3,495 ULM H S H Public and TB High Government and private /decreasing insurance Lao PDR 1,320 LM H S H Public TB High/ decreasing? Mostly government Government and insurance Mixed government and insurance Mostly government Malaysia 9,977 UM H H M Public and AIDS, TB, None/same Mostly government Insurance? private Malaria Myanmar NA L H S S Mostly public AIDS, TB, High/ Government / OOP Government Malaria increasing? Philippines 2,370 LLM H S M Public and AIDS, TB, High for TB Mostly insurance Mostly insurance private Malaria and malaria, less for AIDS. All decreasing. Thailand 4,972 UM H S M Public and AIDS Low/same Mostly insurance Mostly insurance private Vietnam 1,407 LLM H S M Mostly public TB, AIDS TB/medium AIDS/ high. Mostly government Both decreasing [1] UM = Upper Middle, ULM = Upper-Lower Middle, LM = Lower Middle, LLM = Lower-lower middle, L = Low. [2] S = Severe, H = High, M = Moderate, L = Low. [3] Some of the AIDS program financing is covered from the provision of free drugs and government subsidies to the insurance scheme. TB government, OOP, insurance. AIDS mostly government 6
Indonesia challenges - TB One of the highest TB burdens in the world and further scaling up is needed, especially to treat large number of MDR-TB cases. Economic burden of US$ 2 billion based on 2011 incidence and treatment rates (service costs, patient costs and productivity losses). Additional funding needed for projected increase in treatment costs from US$ 77.5 million in 2011 to US118.5 in 2016. which will reduce economic burden to US$ 1 billion. 7
Indonesia challenges - TB High but reducing levels of donor funding. National social insurance from 2014 aiming to cover the whole population by 2019 but premium not enough to cover all TB services. Roadmap is being prepared to show how costs will be covered from national and local government budgets and insurance over next 10 years. 8
Indonesia challenges - TB Need to ensure fragmented financing does not result in fragmented TB control program Challenge of ensuring adequate financing under a decentralized health system with around 500 autonomous local government units deciding on health and TB allocations. Need for policy levers including sticks (no DOTS no reimbursements) and carrots (provider and patient incentives) 9
Viet Nam challenges - AIDS New infections have reduced and treatment with ARVs has increased, but significant scaling up is needed. 73% of the AIDS program funding and 97% of ARV costs are funded by donors who are seeking to reduce funding significantly. Government tax base is low and contribution from insurance is low. Examination and treatment for PLWHIV is included in the benefits package but only 8% to 30% of PLWHIV have health insurance cards. Still seeking sustainable financing solution. 10
Research findings ATM control costs are likely to continue to increase in all countries and in some countries that is likely to happen at the same time that donor funding falls Government commitment is essential but is not generally strong and more and better advocacy is required In some cases service delivery systems may need to be restructured to be more cost-effective, efficient and affordable. This will need to take into account the degrees to which the programs should be vertical or integrated Better evidence on costs and cost-effectiveness is needed to support service and financial restructuring and advocacy 11
Findings The main sources for financing are likely to be government budgets and health insurance, and an important challenge will be to find the combination of these that will produce the best programmatic results National social insurance will only be able to provide additional revenue for health (including ATM) if there is a sufficient base of private sector companies and employees to contribute. The push to universal health coverage (UHC) should support the sustainability of the ATM programs but the UHC goal of getting essential packages of health services to whole populations will also require substantial financing which may restrict the availability of additional ATM program financing 12
Findings Financing policies and payment mechanisms should form an integrated package of policy levers, such as supportive government regulations, using insurance to enforce good practices and using incentives to strengthen weak links Human resources and essential medicines and supplies are key elements of sustainability and require separate financing (and programmatic) strategies The roles of the private health sector both for-profit and NGOs and CBOs can be important in terms of getting services to the people and should be taken into account when developing the financial sustainability strategies 13
Acknowledgments and contacts Ministries of Health representatives in the countries involved USAID TB CARE I Project Authors: David Collins (MSH) - contact dcollins@msh.org Dyah Mustikawati (NTP Director, MOH, Indonesia Firdaus Hafidz (Universitas Gadjah Mada), Indonesia Julie Rostina (MSH) Information on MSH health care financing work and tools http://www.msh.org/our-work/health-system/health-care-financing 14