This document discusses universal health coverage (UHC) and challenges in achieving it. It notes that UHC aims for all people to access health services without financial hardship. Achieving UHC requires more resources, raising funds fairly, and efficient spending. Most countries spend too little. Out-of-pocket payments deter use and impoverish people. Pooled funds through prepayment are better. Research is needed to understand inequities and improve programs. Community involvement may help transform health insurance for the poor. More comprehensive systems combining financial, supply, and management reforms are needed to organize accessible, quality care for all.

1. Financing for Universal Health Coverage (UHC) EPHP 2010 Bart Criel Institute of Tropical Medicine Antwerp, Belgium

2. Contents What is UHC about? World Health Report 2010 Health systems financing: the path to universal coverage What are the challenges for Indian policy-makers? Which role for what kind of research? Which way forward towards towards UHC?

3. UHC: what is it about? Everyone should be able to access health services and not be subject to financial hardship in doing so Call for UHC consistent with… Alma-Ata declaration (1978) World Health Assembly resolution 58.33 (2005) World Health Report PHC, now more than ever (2008) Commission on Social Determinants of Health report (2008) …

4. Changing global policy environment Sociological changes Growing public demand and expectations More vocal civil society Medical-clinical changes Epidemiological transition: NCD, aging,… with increasing costs of health care New treatments Policy / Political changes Equity (back) high on the agenda (following SDH)

5. Use of curative care consultation as indicator for access: facts are stronger than a Lord Mayor Average sub-Saharan country - less than 0.5 contacts per capita per year at level of first line health services - less than 10 hospital admissions per 1000 inhabitants per year -> considerable under-utilisation (of modern care in formal services) Belgium: approx. 10x higher - 4 to 5 contacts per capita per year at general practice level - 150 hospital admissions per 1000 inhabitants per year

6. Health care financing needs What to do (in low-, middle- and high-income countries) ? 1. Need for more resources 2. Need to raise them in a more fair manner 3. Need to spend / allocate these resources in a more efficient way

7. How much is spent? How much needed? OECD countries spend on health on average US$ 3600 per capita per year 31 of WHO’s member states spend less than US$ 35 4 member states spend less than US$ 10 India spends approximately US$ 50, of which 80% is out-of-pocket Recent estimates of financing needs: On average US$ 60 per capita per year will be needed in 2015 (including antiretrovirals and care for non-communicable diseases)

8. Limitations of direct payments Direct payments (user fees, out-of-pocket payments) Regressive by nature Deter poor people from (needed) utilisation Source of impoverishment Dr Margaret Chan: User fees have punished the poor Exemptions often do not work Loss of income for providers Stigma, discriminating behaviour, bureaucracy

9. More OOP in poorer countries… Source: WHR 2010 p42

10. … and higher risk of impoverishment In terms of catastrophic health expenditure, and ultimately in impoverishment Source: WHR 2010 p43

11. Non-financial barriers also matter Distance Culture, language, gender Perceived quality of care … Discriminatory practices Stigma Lack of information … J.T Hart (The Lancet, 1971) : the inverse care law The availability of good medical care tends to vary inversely with the need for it in the population served

12. ‘ Omnio’ programme in Belgium Belgium: 15% of its population is ‘BPL’ Omnio is a government programme that aims at enhancing financial access to health care in Belgian Social Health Insurance system for highly vulnerable population groups Benefit for BPL: reduced co-payments when using care Only 25% of total entitled population (800.000 HH) makes use of Omnio after several years of operation Why? Lack of information People have to apply for it themselves Complex administrative procedures

13. The medical poverty trap Poverty ill health Poverty - Poor access to quality care - Social Determinants of (ill) Health - Catastrophic Health Expenditure - Lack of Social Protection in Health

14. 1. Need for more resources Increase efficiency of revenue collection Reprioritise government budgets Innovative financing Development assistance for health

15. 2. Remove financial barriers to access Prepayment and pooling Subsidise for the poorest Ideally, mandatory contributions Go for large numbers of people pooling funds

16. 1. Who is covered from pooled funds? Breadth 2. What services are covered? Depth 3. How much of the cost is covered? Height Breadth of coverage Height of coverage Depth of coverage Source: WHR 2010 p12

17. 3. Promoting efficiency and eliminating waste According to the 2010 World Health Report, about 20-40% of resources spent on health are wasted E.g. drugs Provider payment systems …

18. Change is possible: yes, we can Countries with similar levels of health expenditure achieve sometimes strikingly different results No single mix of policies works well in every setting Need for home-grown strategies - Path-dependency - Pragmatism vs dogmas - No copy and paste ‘ Succes stories’ Brazil, Chile, China, Mexico, Rwanda, Thailand, Gabon, Cambodia, Lebanon, Ghana… … have made substantial progress

19. The ‘Triangle that Moves the Mountain’ Relevant knowledge via research Social movement Political involvement The Thai example

20. The case of India Underfunded government health sector: government expenditure on health is 1% of GDP Bulk of health care expenditure in India is OOP Fragmented health system: the main divides Public-Private Clinical Medicine - Public Health Horizontal – Vertical

21. Policy priorities in India Messages for policy-makers More financial resources Increase funding to public sector More resources raised in a fair way Reduce reliance on direct payments and shift further to prepayment and pooled funds More efficient use of scarce resources Rationalisation measures at supply-side of care A number of current public programmes already go in that direction: NRHM (Health) RSBY (Labour) …

22. Need for a systemic approach for synergy 1. Enhance access Lift barriers to care - financial and others 2. Rationalise the provision of care Resources Provider behaviour 3. Organise and manage local health systems with a clear vision in mind Pluralistic and integrated systems based on Primary Health Care 1. Demand-side interventions 2. Supply-side interventions 3. Management of the Local Health System The intervention triade

23. 1 st Global Symposium on Health Systems Research Montreux, Switserland, 16-19 November 2010 Universal health coverage with equity: what we know, don’t know and need to know (Frenz & Vega, background paper) www.hsr-symposium.org Messages for researchers: Important gaps in knowledge about why health needs for some groups are not being met by UHC programs… Research should go beyond just reporting inequities in health care utilisation to explaining the causes of differential access Need for a more comprehensive understanding of equitable care, which integrates a sociological perspective and uses mixed quantitative and qualitative methodologies

24. Research on CHI in India: not only an effective strategy, also a social investment Community health insurance contributes to universal health coverage in India PhD thesis 2010 (Devadasan) If well designed and implemented, CHI schemes in India can increase access to hospital care and protect households from Catastrophic Health Expenditure Community Health Insurance and Universal Coverage: Multiple paths, many rivers to cross World Health Report (2010) Background Paper 48 (Soors, Devadasan, Durairaj and Criel) Research in Mumbai and Pune confirms the potential for bottom-up empowering of CHI members The government – in addition to its top-down approach – should tap the potential of community organisations to transform the RSBY target groups from passive beneficiaries into active participants

25. Socially Inclusive Health Care Financing in West Africa and India ( Health Inc .): a EU-funded research project Hypothesis: Social exclusion is an important cause of the limited success of recent health financing reforms Health Inc. will analyse: (i) whether financing arrangements can overcome social exclusion to successfully cover poorer population groups (ii) whether these arrangements succeed in increasing social inclusion by empowering socially marginalised groups . Fields: India (Karnataka, Maharashtra) Ghana Senegal Partners: India: IPH Bangalore & TISS Mumbai Ghana: ISSER Accra Senegal: CREPOS Dakar Europe: LSE London & ITM Antwerp Start: May 2011

26. Way forward: what is needed? More resources More fairness in raising these resources More efficiency in using these resources But financing is a means to an end: What are the resources for? Need for a clear and shared vision on how to organise (local) health care delivery systems that offer accessible quality care to all who need it

27. Thank you

28. 5 presentations Gautam Chakraborty : Patterns of Public Health expenditure in India: Analysis of State and Central Health Budgets in pre- and post-NRHM period K. Gayithri : District fund flow under NRHM and service delivery. Some insights from Karnataka KG Santhya : Conditional cash transfers and quality of care of maternal and newborn care. Womens’ experiences of Janani Surksha Yojana in Rajastan Sulakshana Nandi : A study to analyse implementation of RSBY in Chattisgarh Shridar Kadam : A Rapid Evaluation of the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh

29. 3 posters Sapna Surendran : Effective utilisation of National Rural Health Mission Flexi-funds in Jharkand: Facilitators, Barriers and Options N Devadasan : Performance of Community Health Insurance in India – findings from empirical studies Manoja Das : Janani Suraksha in Jharkhand. Detreminants of utilisation of conditional cash transfer scheme and institutional delivery