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![How could reinforcing the financial protection improve the
health of disadvantaged subpopulations?
UHC Action Framework for Western Pacific: example areas
• 3.1.1a. Increase prepayment on health, including through government general revenue and
statutory health insurance, and reduce the service cost to patients.
• 3.1.1b. Use prepayment to minimize catastrophic expenditure for life-saving interventions.
• 3.1.1c. For population-level health services, target underserved populations, areas or
health conditions.
• 3.1.1d. For individual-level services, introduce subsidies for both direct and indirect costs to
improve health service uptake by those who cannot afford to pay […]
• 3.1.1e. Reduce fragmentation of financing schemes and benefit packages to maximize
solidarity.](https://image.slidesharecdn.com/day2session3financingandgovernancev24october20161-161108012532/75/Day-2-session-3-financing-and-governance-v24_october2016-1-13-2048.jpg)
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Day 2 session 3 financing and governance v24_october2016 (1)
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- 2. Financing Source. World HealthReport 2010 Dimensions of reforms for UHC: 1) Population coverage, 2) health service coverage and 3) cost coverage.
- 3. Health insurance coverage Source:D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue- 4/issuetoc?campaign=woletoc
- 4. Financial catastrophe • Inthe Asia Pacific region, an estimated 105 million people suffer financial catastrophe, and more than 70 million are impoverished, because of health care costs. • In 2009, an estimated 3.8 % of total households in Mongolia experienced catastrophic health expenditures, spending more than 40% of their household subsistence income on health. • As in many LMIC, the high share of OOP in health financing in Mongolia negatively affects equity, access and use of health services. Source bullet 1: WHO Regional Office for Western Pacific (2009). Health financing strategy for Asia Pacific region (2010-2015). (Quoted in 2016 WPRO Regional UHC Action Plan Source bullet 2: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015 quoting Ministry of Health (2009) – Policy brief: Distribution of health payments and catastrophic expenditure in Mongolia.
- 5. Out of Pocket(OOP) expenditure Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue- 4/issuetoc?campaign=woletoc
- 6. Reducing OOP • ReducingOOP requires addressing its driving factors, including: – The irrational use of medicines and pricing practices, at least for essential drugs included in the health insurance benefit; – Insufficient private sector regulation that has contributed to cost escalation and growing pressure on all revenue sources. • Consumers are not always aware of their service benefits and copayment obligations under these two fragmented arrangements (health insurance and government health budget). Patients may pay OOP even for publicly-funded health services and medicines. Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015 quoting Ministry of Health (2009) – Policy brief: Distribution of health payments and catastrophic expenditure in Mongolia.
- 7. Extent to whichcosts are covered for particularly vulnerable groups Source: D.Bayarsaikhan, Chimeddagva, S. Kwon. Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage, International Social Security Review. Volume 68, 4/2015.pp 93-113. DOI: 10.1111/issr.12089. http://onlinelibrary.wiley.com/doi/10.1111/issr.2015.68.issue- 4/issuetoc?campaign=woletoc
- 9. Indirect costs • Studyof 39 LMIC: On average, transportation costs were 12% of per-visit treatment charges for outpatient services and 17% of inpatient treatment charges for hospitalization. • WHO (2015) study in Mongolia: The poorest of poor use mostly primary health care facilities rather than the specialized centres and clinical hospitals of tertiary care level. Despite being relatively limited, the use of private health facilities increased for the poorest population in Mongolia. They attend Soum and Family health centres twice more than the richest people and 5-10 times less the private hospitals. The richest people accessed health services at central clinical hospitals and specialised centres 2-3 times more than the poorest people. • Dorjdagva J et al (2016) about Mongolia: lower income groups are less likely to access specialized services at the higher referral levels due to direct costs, including for co-payments, medicines, and consultations, as well as indirect costs, such as for transport and meals. Source: Saksena, P., et al (2010). Health services utilization and out-of-pocket expenditure in public and private facilities in low-income countries. World health report. http://www.who.int/healthsystems/topics/financing/healthreport/20public-private.pdf Source: Dorjdagva J et al (2016). Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health. 2016, https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0395-8
- 10. Cambodia’s Health EquityFunds (HEF) - Autonomous, district-based schemes - Reimburse public health facilities for user-fee exemptions provided to the poor - Subsidize transport and food costs - Coverage: 90% of the poor population (2014) - Finance: development partners + domestic funding Source: Universal Health Coverage: Moving Towards Better Health – Action Framework for the Western Pacific Region. Manila: World Health Organization Western Pacific Region; 2016. Photo credit: Angela Savage/IPS
- 11. Financing for progressiveuniversalism even in the context of economic downturns • Mitigating the pressures posed by economic downturns requires: – weighing short-term cut-saving measures against longer-term priorities; – avoiding arbitrary cuts to coverage, budgets, infrastructure, staff numbers, etc, which are unlikely address underlying performance issues and may cost the health system more in the longer term; – securing financial protection and access to health services as a priority, especially for the most disadvantaged subpopulations; – focusing on promoting efficiency and cost-effective investment; – reviewing the health financing policy design and considering who will be left out by the changing social context and existing approaches to entitlements; – strengthening cross-sectoral cooperation (in particular with social and fiscal policy domains) to address factors outside of the direct control of the health sector. Source: WHO Regional Office for Europe (2014b). Economic crisis, health systems and health in Europe: impact and implications for policy. Sarah Thomson, et al. http://www.euro.who.int/__data/assets/pdf_file/0008/257579/Economic-crisis-health-systems-Europe-impact-implications-policy.pdf
- 12. Reducing unnecessary expenditureon medicines and using them more appropriately, and improving quality control, could save countries up to 5% of their health expenditure (Source: WHR 2010). Increasing efficiencies – tackling unnecessary expenditures on medicines (extracted top 3 only)
- 13. How could reinforcingthe financial protection improve the health of disadvantaged subpopulations? UHC Action Framework for Western Pacific: example areas • 3.1.1a. Increase prepayment on health, including through government general revenue and statutory health insurance, and reduce the service cost to patients. • 3.1.1b. Use prepayment to minimize catastrophic expenditure for life-saving interventions. • 3.1.1c. For population-level health services, target underserved populations, areas or health conditions. • 3.1.1d. For individual-level services, introduce subsidies for both direct and indirect costs to improve health service uptake by those who cannot afford to pay […] • 3.1.1e. Reduce fragmentation of financing schemes and benefit packages to maximize solidarity.
- 14. How could reinforcingthe financial protection improve the health of disadvantaged subpopulations? UHC Action Framework for Western Pacific: example areas • 3.1.2a. Understand the impacts of health financing and social protection schemes, especially for vulnerable populations like older people, women, those with disabilities, children and the poor. • 3.1.2b. Build potential synergies by linking financial protection mechanisms in health with broader social protection mechanisms. • 3.2.2b. Provide targeted financial incentives, including vouchers or conditional case transfers, matched with adequate supply to improve use, especially of preventive and routine services.
- 15.
- 16. Source: WHO RegionalOffice for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Manila: World Health Organization; 2016. Quality Efficiency Equity Accountability Sustainability and resilience • Regulations • Effective, responsive services • Individual, family and community engagement • Health system architecture • Incentive for appropriate provision and use of services • Managerial efficiency and effectiveness • Financial protection • Service coverage and access • Non- discrimination • Government leadership • Partnerships • Transparent monitoring and evaluation • Public health preparedness • Community capacity • System adaptability and sustainability
- 17. Accountability Action Domains: 4.1 Governmentleadership and rule of law for health 4.2 Partnerships for public policy 4.3 Transparency, monitoring and evaluation a. Set the vision for health sector development and ensure sufficient resources for health b. Strengthen the rule of law and regulatory institutions c. Build leadership and management capacities a. Secure intersectoral collaboration across government b. Work with non-state partners on shared interests for health c. Empower communities to participate in decisions and actions that affect them a. Develop efficient health information systems and streamline information flows b. Foster open access to information c. Strengthen institutional capacity for health policy and systems research and translation of evidence into policy
- 18. • Urged MemberStates, among other things, to: – “Prioritize health system strengthening for UHC, with a special emphasis on the poor vulnerable and marginalized segments of the population”; – “Cooperate across government sectors to tackle social, environmental and economic determinants of health, to reduce health inequities, in particular the empowerment of women and girls, and contribute to sustainable, including “health in all policies” as appropriate”; • Emphasized the need for community engagement. Government leadership: WHA Resolution 69.11 Health in the 2030 Agenda for Sustainable Development
- 19. Cooperation with othersectors
- 20. Registration issues (example ofMongolia) • Situation Analysis Survey of ADB in 2010: – Only 25% of unregistered residents could obtain health services while 62.2% of registered residents can. – One third of the respondents did not access primary care when they needed to because of: • a lack of money (77.5 %), • no health insurance (55.9%), and • being too far away (31.8%). – The government has taken actions to improve the civil registration system through social welfare programmes and targeted interventions. This helps rural–urban migrants to be registered and improved access to health services. Source: WHO (2013). Health Systems in Transition: Mongolia Health Systems review. Asia Pacific Observatory on Health Systems and Policies. http://www.wpro.who.int/asia_pacific_observatory/hits/series/Mongolia_Health_Systems_Review.pdf
- 21. Participation • UHC ActionFramework for Western Pacific: example areas – 1.3.1b. Create a platform for individuals, mass media and health advocacy groups to exchange information and engage with providers and relevant stakeholders. – 1.3.2a. Establish a system for families and communities to give feedback on the patient journey, for example through patient experience surveys. – 1.3.2b. Institute conciliation and resolution mechanisms for medical error, complaints and concerns, with involvement of affected patients’ representatives. – 1.3.3b. Promote the creation of peer support groups to share knowledge and experience. Source: WHO Regional Office for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. Manila: World Health Organization; 2016.
- 22. Redress mechanisms Source: FeedbackMatters: Designing Effective Grievance Redress Mechanisms for Bank-Financed Projects. Part 1: The Theory of Grievance Redress World Bank’s Social Development Department, 2011 http://documents.worldbank.org/curated/en/342911468337294460/The-theory-of-grievance-redress • Well-designed and -implemented Grievance Redress Mechanisms (GRMs) can enhance operational efficiency, accountability and transparency ways including: – generating public awareness about services, entitlements and obligations; – deterring fraud and corruption; – mitigating risk; – providing staff with practical suggestions/feedback that allows them to be more accountable, transparent, and responsive to beneficiaries; – assessing the effectiveness of internal organizational processes; and – increasing stakeholder involvement.
- 23. Redress mechanisms Source: FeedbackMatters: Designing Effective Grievance Redress Mechanisms for Bank-Financed Projects. Part 1: The Theory of Grievance Redress World Bank’s Social Development Department, 2011 http://documents.worldbank.org/curated/en/342911468337294460/The-theory-of-grievance-redress
- 24. Information and transparency •UHC Action Framework for Western Pacific: example areas – 4.3.2a. Establish mechanisms and a legal environment for fostering access to information generated by governments, health facilities, insurance organizations and procurement agencies. – 4.3.2b. Make data available on financial resources, expenditures, health service indicators and health indicators in a timely manner and user-friendly formats to improve health system performance. – 4.3.2c. Engage civil society organizations and communities in a participatory process for data generation, interpretation and transfer. Source: WHO Regional Office for Western Pacific (2016). Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. Manila: World Health Organization; 2016.
- 25. Transparency: Knowing the issuesto be addressed (example from European Union countries) • A European Commission study on corruption in the health sector conducted in 2013 developed a typology of six main types of corruption: – bribery in medical service delivery (informal payments), – procurement corruption, – improper marketing relations (generally between physicians and industry), – misuse of high level positions, – undue reimbursement claims (insurance fraud), and – fraud and embezzlement of medicine and medical devices (European Commission, 2013). • Their method of measuring corruption included collecting and analyzing 86 “cases” of corruption in European nations and interviewing key informants. Source: European Commission (2013). Study on Corruption in the Healthcare Sector. European Commission – Directorate-General Home Affairs. Brussels. https://www.stt.lt/documents/soc_tyrimai/20131219_study_on_corruption_in_the_healthcare_sector_en.pdf
- 26. Transparency and accountabilityissues – example impact on the MDGs Source: Vian T and Noguchi J (2014). Corruption in the Health Sector: Implications for Economic Development. A sectoral assessment prepared as input to the OECD study Consequences of Corruption at the Sector Level and Implications for Economic Development.
- 27. Participation Participation Participation Accountability Accountability Accountability TransparencyTransparency Transparency InformationInformation Information Resilience Settingstrategic directions - Planning – Financing – Regulation – Purchasing – Inspection, audit, evaluation Direct public and private health service providers – Pharmaceutical industry and suppliers – Training institutions – Research institutions – IT solutions Consumer and patient associations – Parliamentary groups and elected citizen representatives Types of relationships: - Laws and regulations - Hierarchy / autonomy - Fund flows / financing mechanisms - Contracts and incentives - Supervision, reporting, monitoring - Evaluation Source: Elaborated by Myriam Bigdeli (WHO Governance team/HQ) based on Brinkerhof and Bossert.
- 28. How can governancebe strengthened to improve the health of disadvantaged subpopulations? UHC Action Framework for Western Pacific: example areas • Government leadership and rule of law • Regulations and regulatory environment (e.g., private sector costing of services) • Individual family and community engagement • Managerial efficiency and effectiveness • Partnerships for public policy • Transparent monitoring and evaluation
Editor's Notes
- #6 As of 2013, health insurance accounted for only 20% of GGHE and it is now the third most-important funding source after the government health budget and direct OOP payments, which alone account for 40 percent of the total health expenditure in Mongolia.
- #11 Started in 2000 in Cambodia – and later introduced in the Lao People’s Democratic Republic – health equity funds are autonomous, district-based schemes that reimburse health facilities for the cost of user-fee exemptions at public health facilities provided to the identified poor and also subsidize the costs of transport and food required during health-seeking episodes. As of 2014, HEF covers 90% of the poor population in Cambodia. More than half of the funding comes from development partners, but the Government is strongly committed to increasing domestic funding to sustain HEF.
- #20 WHA (2016). Health in the 2030 Agenda for Sustainable Development. World Health Assembly resolution 69.11 Geneva, http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R11-en.pdf the Goals and targets of the 2030 Agenda for Sustainable Development are integrated and indivisible, balance the three dimensions of sustainable development (the economic, social, and environmental), importance of health systems strengthening as it is critical to the achievement of all targets of SDG 3 URGES MS: (2) to prioritize health system strengthening, including ensuring an adequately skilled and compensated health workforce, in order to achieve and sustain universal health coverage, defined as universal access to quality promotion, prevention, treatment, rehabilitation and palliation services, including access to safe, effective, quality and affordable essential medicines and vaccines for all, ensuring financial protection from out-of-pocket expenditure on health for all with a special emphasis on the poor, vulnerable, and marginalized segments of the population2 as fundamental to the achievement of the 2030 Agenda for Sustainable Development; URGES MS (3) to emphasize the need for cooperative action at the national, regional, and global levels across and within all government sectors to tackle social, environmental and economic determinants of health, to reduce health inequities, in particular through the empowerment of women and girls, and contribute to sustainable development, including “Health in All Policies” as appropriate; Emphasizing the need for community engagement to focus attention on more rational and forward-looking integration of health workers at community level into functional health systems aligned with country objectives and actions, and on recognizing them as key players to extend and deliver basic health services directly to communities to achieve the Goals of the 2030 Agenda for Sustainable Development;
- #24 Well-designed and -implemented GRMs can help project management significantly enhance operational efficiency in a variety of ways, including generating public awareness about the project and its objectives; deterring fraud and corruption; mitigating risk; providing project staff with practical suggestions/feedback that allows them to be more accountable, transparent, and responsive to beneficiaries; assessing the effectiveness of internal organizational processes; and increasing stakeholder involvement in the project.
- #28 Vian T and Noguchi J (2014). Corruption in the Health Sector: Implications for Economic Development. A sectoral assessment prepared as input to the OECD study Consequences of Corruption at the Sector Level and Implications for Economic Development.