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Universal Health Coverage (UHC) Day 12.12.14, Nepal


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This presentation is made on the first ever Universal Health Coverage (UHC) Day 12.12.14 celebration in Nepal by Nepal Health Economics Association (NHEA).

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Universal Health Coverage (UHC) Day 12.12.14, Nepal

  1. 1. Universal Health Coverage Day, 12 December 2014 Let’s Get Started
  2. 2. Presentation by Deepak Kumar Karki, General Secretary, NHEA Devi Prasai, Vice-President, NEHA Shiva Raj Adhikari, Member, NHEA
  3. 3. For Today Universal Health Coverage (UHC): Progress So Far and Way Forward in Nepal
  4. 4. What is Universal Health Coverage? Universal health coverage means that every person, everywhere, has access to quality health care without suffering financial hardship.
  5. 5. Why Now? (1) Health is a human right and a cornerstone of sustainable development and global security Universal health coverage changes the way that health care is financed and delivered – so it is more equitable and more effective
  6. 6. Why Now? (2) Because Nobody should go Bankrupt when They Get Sick Because UHC is Attainable Because UHC can Stop the World’s Biggest Killers Because Health Transforms Communities, Economics and Nations Because Health is a Right, Not a Privilege
  7. 7. Background of UHC Human dignity •Recognizes that inequalities in access to treatment or gross disparities in health outcomes creates indignity Human security •Recognizes that forced payments for healthcare are a source of insecurity Solidarity • Implies that the burden of funding healthcare be distributed fairly, and that the better-off should assist the worst-off.
  8. 8. Taking the Note • United Nations GA/67 Session Global Health and Foreign Policy Adopted on 12 December 2014 • World Health Report 2010, entitled “Health systems financing: the path to universal coverage” • Social Protection Floor Initiative endorsed by the United Nations Chief Executives Board for Coordination in April 2009 • Mexico City Political Declaration on Universal Health Coverage, adopted on 2 April 2012 • Bangkok Statement on Universal Health Coverage, adopted at the Prince Mahidol Award Conference on 28 January 2012 • Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector, adopted on 5 July 2012
  9. 9. Why UHC? As a means to achieve better health or poverty reduction or sustainable development outcomes Equity in outcomes or opportunities or risk protection are important as ends in themselves
  10. 10. Requirements in measuring UHC 1. Measures of ends • Indicators that assess the extent of UHC attainment across countries in comparable and consistent manner to inform policy and research • To assess relative performance • To assess improvements • To help identify critical factors 2. Measures of means • Indicators that assess critical factors that enable or prevent attainment of UHC • E.g. Public financing, risk-pooling, etc.
  11. 11. Definition “Every citizen will have access to and utilization of highest attainable standard of services without financial difficulties”. WHO Every citizen will have access to and utilization Population Coverage highest attainable standard of services Service coverage with quality Without financial difficulty Financial coverage
  12. 12. Service coverage
  13. 13. What services do we include? • Cost effective. • Addresses the major burden of disease • Serves the larger population. • Improve health of poor and disadvantaged • Ensuring the right of the citizen • Availability of resource (fiscal space)
  14. 14. Including service may reduce the population coverage of other services 90%90%90% 54%54%54%54%54% Ensure the additional resource for added services 30%30%30%30%30%30%30%30%30% 3 services 5 services 9 services Options 3 Options 2 Options 3
  15. 15. Adding service increases level of financial protection Out of Pocket expenditure 74% Hotchkiss at al, 1998 9 services Out of Pocket expenditure 62.5% Prasai et al, 2006 Adding CB IMCI, 10 services Out of Pocket expenditure 60 % Shrestha et al,2011 Adding 4 more services 13 1996 1999/2000 2006-08
  16. 16. Adding service Before NHSP Included services in NHSP 1 Included services in NHSP 2 Reproductive Health -Medical safe abortion -UP(Prevention and M. Child Health CB IMCI -CB Nutrition, - CB newborn care CD NCD disease control -CB mental health Program -Health promotion NCD -Oral -Eye Care -Rehabilitation of Disabled -Environmental Health Curative Care Outpatient care
  17. 17. National Free Care Policy a step towards UHC Evolution Reforms December 15, 2006 Declared targeted free care at district hospitals and PHCC (inpatients and emergency care) October 8, 2007 Declared the abolishing user fees at HPs/ SHPs Nationwide and made service free to all January 16, 2008- Implemented the policy of free to all health post and sub health post November 16, 2008 Expanded universal free care to PHCC level January 15, 2009 -Declared free outpatient care at DHs to the targeted population nationwide, -Declared 40 free essential drugs free to all at district hospitals nation wide -Declared all essential drugs free to targeted groups nationwide
  18. 18. Service coverage under universal and targeted free are Service covered All people Targeted groups Outpatient care up to district hospital X X Inpatient care X Emergency care X Support services • Routine laboratory test X •General X Rays X Referral service X
  19. 19. Measuring UHC through three dimensions Extend to non-covered Reduce cost sharing & Population: who is covered? fees Direct costs: proportion of the costs covered Current pooled funds WHR, 2010
  20. 20. Reforms is Needed in the Health System • The implementation plan for universal coverage must improve all dimensions of the health system. • These dimensions include • the ‘breadth’ (number of people protected), • the ‘height’ (proportion of costs covered), and • the ‘depth’ (range of services and benefits covered), • as well as those additional factors that influence quality and safe services that contribute to improving health status
  21. 21. Breadth: population covered • Coverage breadth: 100% population coverage: • All population groups and their families need to be covered: • Formal sector employees, informal sector workers, self-employed, unemployed, students, pensioners, rural/urban, rich/poor, dalit/nondalit …
  22. 22. Population Coverage: service consultation and self-reported adequacy of services Percentage of service consultation Percentage of self reported adequacy of health services
  23. 23. Access to Health Services
  24. 24. Breadth (increasing the number of people protected by the health systems) • Addressing physical, financial and access limitations. • Strategies may include: • Increasing the staffing levels of primary health care (PHC) facilities, changing opening times of clinics; • Encouraging and rewarding collective and integrated group practices; • Changing policies to encourage task-shifting or task-sharing, building more clinics; • Expanding mobile outreach services and home-based care, subsidizing transport to and from health facilities and expanding patient transport services.
  25. 25. Coverage Depth • Coverage depth: • Defined package of service based on market segmentation • Available resources: • What can the country afford? • Health service priorities • Preferences for specific services
  26. 26. Service Coverage: Using Tanahashi Model
  27. 27. Service coverage: some examples
  28. 28. Depth – increasing the range of services and benefits covered by the system • Service packages for various levels of care, aligned to local burden of disease, define access and related services. • Changes in facility staffing to allow a greater range of services to be provided at designated PHC service delivery points, task-shifting or task sharing • To reduce the time costs of highly skilled professionals (including shifting nursing tasks from professional nurses to nursing assistants and from doctors to nurses and other assistants) and spending more on health services than in the past. • Decide necessary on the scope of the essential service package and on initiating periodic reviews of the package
  29. 29. Coverage Height • The emphasis is on prepaid and pooled contributions to the health financing system • Tax -based financing • Social health insurance • Mix of tax - based financing • Mixes of community, Cooperative and enterprise-based health insurance, other private health insurance
  30. 30. Financial protection Protecting people from: • financial consequences of illness and death • financial consequences associated with the use of medical care No financial hardship associated with ill health • Curative, preventive, promotive and rehabilitative services What is the role of direct out-of-pocket (OOP) payments? • Inequitable and inefficient !
  31. 31. % Change in THE between 2000 and 2012 Health expenditure has grown faster than income on a per capita basis . Health expenditure as a percentage of GDP in 2012 was 5.5 % in Nepal, an increase of 0.4 percentage points from 2000.
  32. 32. Change in share of public expenditure and OOP between 2000 and 2012 The share of out-of-pocket has fallen by 19.6 percentage points since 2000. The share of public expenditure has increased by 14.9 percentage points since 2000.
  33. 33. Share of External Resources • External resources accounted for 10.1 % of total health expenditure in Nepal. • There is negligible change in share of external resources between 2005 and 2012.
  34. 34. Financial Coverage Total Health Expenditure by Financing Sources 17.3 19.8 23.7 18.5 20.8 21 61.5 60.5 55.6 65.7 62.5 60.5 21.1 19.7 20.8 15.8 16.7 18.5 80 60 40 20 0 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 In Percent Fiscal years General government Private sector Rest of the World
  35. 35. Financial Coverage 5.0 5.2 THE as % of GDP 5.1 5.7 5.6 5.3 4.9 5.3 5.3 5.8 5.6 5.4 5.2 5.0 4.8 4.6 4.4 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Per cent Fiscal Years
  36. 36. Out of Pocket Payment and Payment for Medicines in Nepal 61.5 60.5 55.6 65.7 62.5 60.5 OOP as % THE 34.5 32.6 26.0 30.8 27.7 26.0 Medicine as % of THE 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
  37. 37. Per Capita GDP and THE 294 323 350 390 464 465 Per capita GDP in USD Per capita THE in USD 16.8 18 18.6 19.3 24.9 24.8 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
  38. 38. Government Expenditure and Medicine Payment 1.5 1.5 1.6 1.5 2.0 2.1 Public health Expenditure as % GDP 34.5 32.6 26.0 30.8 Medicine as % of THE 27.7 26.0 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
  39. 39. Impact of OOP Financial shocks or welfare loss
  40. 40. Assessment of FP in Health • Financial protection is generally assessed: • based on out-of-pocket (OOP) spending on medical care • and such payments are related to a threshold (e.g., poverty line) • Two methods: 1) Catastrophic spending  Medical outlays that exceed a certain threshold (z) of household income or resources (incl. non-subsistence expenditure). 2) Impoverishment  Medical outlays that are sufficient enough to dip a non-income poor household into poverty
  41. 41. Catastrophic and Impoverishing Impact OOP impacts have increased, such as the catastrophic impact (or financial shocks) have increased 6 percent to 11 percent at 10 percent threshold from 1995/96 to 2003/04. Similarly, improvising impact has increased 2.2 to 2.5 percentage point same study period.
  42. 42. Financial Coverage 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Catastrophic incidences based on total consumption 5 10 15 25 Share of Ability to pay (incidence) Thresholds Levels NLSS I NLSS II NLSS III
  43. 43. 50% 40% 30% 20% 10% 0% Financial Coverage Catastrophic Incidences based on Non-Food Consumption 5 10 15 25 40 Share of Non Food Consumption Threshold levels NLSS I NLSS II NLSS III
  44. 44. OOP Impact on Poverty
  45. 45. Financial incidence analysis The results from two Nepal living Standards Survey data 1995/96 and 2003/04 suggests better off pay more for health care not only in absolute terms but also relative to income. But poor don’t utilize health care as per their needs.
  46. 46. Health Care Utilization Consumpti on quintile Consulted Not consult ed Tota Kabiraj/Baid ya Tradition al Doctors Paramedic l Poorest 8.1 42.4 1.1 5.4 43.1 100 second 16.6 40.1 0.2 2.9 40.3 100 Third 20.6 42.4 0.2 2.5 34.4 100 Fourth 30.9 34.3 1.2 4.3 29.3 100 Richest 45.7 25.2 1.4 1 26.8 100 • It does not mean that poor are comparatively healthier than the rich people. • In fact, they have greater incidence of disease but their inability to meet basic requirement such as food availability makes them compelled to overlook health problems.
  47. 47. Who gets benefit from health care? 0.3664 0.4932 0.2943 0.4642 0.2987 0.0281 Gini Hospital care Non hospital care 1995/96 2003/04 All concentration indices for hospital care and non-hospital care are significantly positive, indicating pro-rich bias. But the concentration indices for non-hospital care are much closer to zero, indicating proportionality than those for hospital care.
  48. 48. Who gets benefit from health care?.... 0.1268 Kakwani Index 1995/96 2003/04 -0.0677 -0.1350 -0.4070 Hospital care Non hospital care The Kakwani indices are significantly negative in 2003/04 indicating that public health care is income inequality reducing, despite the fact that it typically not pro-poor. Non-hospital care has greater power to reduce income inequality than hospital care.
  49. 49. System of health financing
  50. 50. Free Health Care Facility Charge SHP Khodpe, Baitadi Rs 10 Health Post Siddheshwore Baitadi Rs 10 PHC Patan, Baitadi Rs 5 PHC Manglabare, Morang Rs 10 PHC Manthali Rammechhap Rs 20 SHP Okhreni Ramechap Rs 10 HP Those Ramechap Rs.10 Thada PHC Argakhachi RS 10
  51. 51. Challenges • How to implement policies that mitigate the financial hardships still faced by the poor in using health services • How to identify the poor for premium exemption • How to increase fiscal space to cover those in the informal sector • Exploring the major determinants of the lack of financial protection, including the detailed reasons for lack of financial protection • Assessing equity dimensions to financial risk protection - by age, sex, location, SES, etc.
  52. 52. Health budget competing with other social services budget (growth rate) Education Health Drinking Water Local Development 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 The health sector has benefited in terms of receiving more resources due to fluctuations in drinking water and local development services
  53. 53. Height – increasing the proportion of costs covered by pre-financing (more funding and less waste) • These may include a range of financing options: • Social health protection coverage through national health services, • Social health insurance, community-based insurance and mandated private health insurance • Improvement efficiency of health system • Improving procurement and administrative efficiencies, • Creating synergistic effects For example, using the inputs of other sectors and departments that impact on health determinants, such as water and sanitation, education and women and children These may include a range of financing options: • Social health protection coverage through national health services, • Social health insurance, community-based insurance and mandated private health insurance • Improvement efficiency of health system • Improving procurement and administrative efficiencies, • Creating synergistic effects For example, using the inputs of other sectors and departments that impact on health determinants, such as water and sanitation, education and women and children.
  54. 54. Financing mechanisms • It represents an integrated approach, respects existing coverage and financing arrangements, and can be adjusted to the specific social and economic context of each country • Broadening sources of financing and better use of resources • Money matters to the health care system, but it does not guarantee efficient, equitable, and effective health care services. Health care financing has the power to reform health care delivery and provide incentives to providers to deliver efficient and effective health care • Specific strategies to engage non-state providers to UHC
  55. 55. Engineering of UHC Covering all services but not population Financial coverage but not population and services Population coverage but not Services and financial
  56. 56. Strategies Categorize services into priority classes. Relevant criteria include those related to cost-effectiveness, priority to the worse off, and financial risk protection. First expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. While doing so, ensure that disadvantaged groups are not left behind. These will often include low-income groups and rural populations
  57. 57. Glocalization: Designing of UHC • Global localization = Glocalization • Global agenda and designing and implementing based on local condition (indigenous system) = UHC Glocalization • If Glocalization; UHC for Nepalese citizen • If not Glocalization; Nepalese citizen for UHC • Then, expected outcomes: blame to be given to Nepalese citizen and cost of UHC on the head of Nepalese citizen
  58. 58. UHC is a Long Journey…… Thank You !!!