Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Universal Health Coverage: The Holy Grail?

5,368 views

Published on

Each year, the OHE sponsors a lecture that explores a timely issue in medicine or health economics. At the 22nd Annual Lecture, the issues and challenges of universal health care coverage in low- and middle-income countries were presented by Professor Anne Mills of the London School of Hygiene and Tropical Medicine.

The audio of this lecture now is available at http://news.ohe.org/2014/08/19/annual-lecture-2014-universal-health-coverage/

Published in: Health & Medicine
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Sex in your area is here: ❤❤❤ http://bit.ly/39pMlLF ❤❤❤
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Follow the link, new dating source: ♥♥♥ http://bit.ly/39pMlLF ♥♥♥
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • 12 Signs From The Universe When You Are On The... ➤➤ https://bit.ly/30Ju5r6
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Universal Health Coverage: The Holy Grail?

  1. 1. UNIVERSAL HEALTH COVERAGE: THE HOLY GRAIL? Professor Anne Mills London School of Hygiene and Tropical Medicine Office of Health Economics Annual Lecture London • 9 June 2014 Improving health worldwide www.lshtm.ac.uk
  2. 2. Growth in development assistance for health (data from IHME) Year Billionsof2010USdollars *2011 and 2012 are preliminary estimates
  3. 3. Year Billionsof2010USdollars Disease focus of development assistance for health (data from IHME)
  4. 4. Neglect of health system infrastructure • Recognition that selective support has hampered achievement of long term health gains: eg – Competition for health workers and for health workers’ and managers’ time – Lack of support for cross-cutting systems issues – eg primary care and district infrastructure; general training programmes; drug supply systems – Lack of attention to long term development of sustainable financing system
  5. 5. Per capita expenditure, 2011 Indicator / Income Group Per capita total health expenditure (US$) Per capita government health expenditure (US$) Per capita private health expenditure (US$) Out-of-pocket as % private health expenditure Low-income 31 12 19 76.8 Lower-middle income 80 29 51 87.1 Upper-middle income 417 230 187 72.0 High-income 4575 2811 1764 36.4 Global 1011 604 407 44.6 PPP: Purchasing Power Parity Source: WHO Global Health Expenditure Atlas. Geneva: WHO. Available at: http://www.who.int/nha/atlas.pdf accessed 24/01/14
  6. 6. Significance of out-of-pocket payment: rural South Africa(Goudge et al 2009) • Poor rural area in South Africa with free public primary care and hospital fee exemptions for poor • Survey of 280 households (1446 individuals) • 70% of households had one or more members with health problem • On average, households paying for health care spent 4.5% of monthly household expenditure • 20% of households spent more than 10% • 15% of households spent more than 15%
  7. 7. The goal of universal health coverage • Growing momentum behind universal health coverage as a key global goal – World Health Report 2010 on universal coverage of health care – Declaration of the World Health Assembly urged member states to ‘aim for affordable universal coverage and access for all citizens on the basis of equity and solidarity’ – 2012 declaration by UN General Assembly – Strong lobby to have universal health coverage as goal in post 2015 MDGs: endorsed by WHO DG at 2014 WHA
  8. 8. Key issues • What does universal coverage mean in low/middle income country context? • What can be learnt from the experiences of countries tackling the key challenges in making progress towards universal health coverage? • What are priorities for countries on the path towards universal coverage?
  9. 9. The health system B PROVIDERS OF SERVICES GOVERNMENT/ PROFESSIONAL BODY A POPULATION/ PATIENTS C FINANCIAL INTERMEDIARIES DIRECT PAYMENTS HEALTH SERVICES INSURANCE COVERAGE MONEY (TAXES OR PREMIUMS) REGULATION REGULATIONCLAIMS MONEY PAYMENT (FEES, GLOBAL BUDGET)
  10. 10. What is universal health coverage? • ‘ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ (WHO) • Ie three related objectives: – Equity in access to health services – those who need the services should get them, not only those who can pay for them – Sufficient quality of health services – enough to improve the health of those receiving services – Financial-risk protection – the cost of using care should not put people at risk of financial hardship.
  11. 11. Key components of a system of universal coverage 1. Sources of finance 2. Financial intermediaries 3. Service providers
  12. 12. The health system B PROVIDERS OF SERVICES GOVERNMENT/ PROFESSIONAL BODY A POPULATION/ PATIENTS C FINANCIAL INTERMEDIARIES DIRECT PAYMENTS HEALTH SERVICES INSURANCE COVERAGE MONEY (TAXES OR PREMIUMS) REGULATION REGULATIONCLAIMS MONEY PAYMENT (FEES, GLOBAL BUDGET)
  13. 13. Sources of finance • Mix of sources common: • General tax, payroll tax, other earmarked tax (Philippines, Thailand, Ghana) • Plus Medical Savings Accounts (Singapore, China) • Plus voluntary contributions, copayments (Korea, China, Philippines, Ghana) • Core mandatory financing mechanism needed: social health insurance and/or general tax revenues
  14. 14. Sources of finance • Population in formal (employed) sector (public and private) relatively easy to cover • Social health insurance usually the chosen main route • Challenges are: – Low income workers and self employed in informal sector – Those outside the workforce: young, old, disabled, and unemployed
  15. 15. Extending financial protection to the informal sector • Via compulsory social health insurance • Social insurance scheme cross-subsidises low income worker premiums (Mexico) • Public funds subsidise compulsory health insurance premiums (all Thailand; targeted Korea, Singapore) • Premiums kept low by continuing some supply side subsidies (Colombia scheme for poor households) • Via ‘voluntary’ insurance schemes (Ghana, Rwanda, Philippines, Thailand, China) eg through partial or full subsidies for premiums from tax funding • Via universal entitlement and general tax funding to health services (Thailand)
  16. 16. Extending financial protection to non-working population • Dependants (elderly, children) covered within compulsory social insurance schemes • General tax used to pay for insurance card for poorest and sometimes elderly (Rwanda, Ghana, India – RSBY) • Via universal entitlement and general tax funding to health services
  17. 17. Role of co-payments • Permits contribution rate to be set at a level that is affordable and/or acceptable (Korea, Philippines) • May help to constrain demand in the early (or later) years of extension of coverage (Korea, Philippines) • May be symbol of family responsibilities (Korea, Singapore) • But regressive – weighs most heavily on poorer groups – and discourages use
  18. 18. Kakwani indices for financing sources Tanzania, South Africa, Ghana (Mills et al 2012)
  19. 19. Financial intermediaries • Historical legacy of segmented funds: should aim be single payer system? (Korea merged; Thailand not yet) • Public or private agencies? • One or more public bodies (traditional for social health insurance) • Government regulates competing private insurers within social health insurance arrangements (eg Colombia, discussed in South Africa) • Government contracts with insurance companies to manage schemes (eg RSBY in India)
  20. 20. Rashtriya Swasthya Bima Yojana (RSBY) • Targeted at families below the poverty line • Premium of max Rs750 (£7.50) per family: shared 75%/25% by central/local government; beneficiary family pays Rs 30 pa for registration • Insurance companies bid for contract to insure families in each district • Hospitalisation benefits up to ceiling of Rs 30,000 per family pa (max of 5 beneficiaries per family) • Insurance company contracts a third party administrator to manage the smart card system • Currently 31m active smart cards (families)
  21. 21. Service providers • Public only or public and private? (Thailand SHI, India RSBY) • Benefit package? • List what is included (eg RSBY) or excluded (eg Thailand)? • Ensuring continuum across primary and hospital care problematic • Payment method (avoid fee for service unless within strong global budget) • Encourage strong primary care role: • Primary care gatekeeper (Korea) • Bypass fees (Thailand) • Primary care budget holder (Thailand, sort of) • Extend services first to poorer areas (eg Brazil Family Health Programme)
  22. 22. Development of Thai health system from 1970s (Balabanova et al 2013)
  23. 23. Thai universal health coverage arrangements • Universal coverage via 3 schemes: – Social health insurance for formal sector employees (with public subsidy) – Non-contributory scheme (so, tax funded) for civil servants – Universal coverage scheme (from 2001) for rest of population, general-tax funded • Gradual progress in harmonising benefit package, payment methods, service provision arrangements • Performance: – Relatively equitable: pro poor benefits; financing becoming less regressive; reduction in catastrophic payments – Inequities remain between schemes in benefit package and level of expenditure – Good cost containment in SHI and UC
  24. 24. 0.050 0.075 0.100 0.125 0.150 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 2003 2004 2005 2006 2007 2008 2009 2010 OPvisitsperyear Year Outpatient visits inpatient addmissions IPadmissionspercapitaperyear -0.50 -0.40 -0.30 -0.20 -0.10 0.00 0.10 0.20 0.30 0.40 0.50 2001 2003 2004 2005 Health Centre District Provincial Private Overall Hospital Hospital Hospital Pro-poorPro-rich
  25. 25. Catastrophic health expenditure refers to household spending on health care >10% of total household consumption expenditure 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 1996 1998 2000 2002 2004 2006 2007 2008 2009 Year Q1 (Poorest) Q5 (Richest) All %ofhouseholdsineachquintile Incurringcatastrophichealthexpenditure % 6.8% 2.9% 6.1% 4.7%
  26. 26. Performance concerns with UHC • Concern about rising costs: increased utilisation, expansion of benefit package (eg renal dialysis in Thailand) • Lack of evidence on link between increased coverage and health outcomes • Lack of evidence on relationship of performance to numerous design options • What is best way to make progress in low income countries?
  27. 27. Learning lessons to apply elsewhere • ‘Technical’ assessment – evaluation of performance and explaining it by reference to design features • Performance criteria, eg – Efficiency (allocative, technical) – Equity of financing (who pays?) – Equity of access to care (who benefits?) – Extent of catastrophic payments – Responsiveness • ‘Institutional’ assessment: what political, economic, social and cultural institutions enable governments to pursue universal health coverage?
  28. 28. Key institutional aspects • Existence of a civil service which has the capability to implement programmes and policies: eg merit based recruitment, tenure in office not linked to personal or political patron, hierarchical structures with impersonal application of rules • Existence of institutions which allow the voice of the less-well- off to be expressed in policy debates and decisions • Relative importance of exercise of ‘voice’ and ‘exit’ as influence on performance (do the richer groups work inside the system to improve it or exit to private sector?) • Whether there is the social solidarity needed for merger of funds and universalist approaches (eg South Africa)
  29. 29. Trajectory and priorities • Universal health coverage is process over time, not a fixed point that can be achieved • Critical to put the necessary elements in place early: – Combination of financing sources – Strong purchasing role encompassing both public and private providers and including emphasis on health promotion and prevention – Payment systems with appropriate incentives for cost containment and quality of care – Strong primary care and ‘district’ level infrastructure with good geographical access

×