Structure and governance of financing - Tamas Evetovits, WHO
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This presentation was made by Tamas Evetovits, WHO, at the 2nd Health Systems joint Network Meeting for Central, Eastern and Southeastern European Countries held in Tallinn, Estonia, on 1-2 December 2016
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Structure and governance of financing - Tamas Evetovits, WHO
- 1. Division of Health Systems & Public Health Spending on health and financial protection: Why and how? Dr. Tamás Evetovits Head of Office WHO Barcelona Office for Health Systems Strengthening Tallinn, 1 December, 2016
- 2. Improving the dialogue between health and finance: why and how? Health officials: Give us more money, we know how to spend it well. Finance officials: Improve efficiency first and then we may give you more Make a better case for more public spending on health Understand poverty and health impact of high out-of-pocket spending
- 3. How do we know what is not sufficient level of spending on health?
- 4. AT BE BG CY CZ DK Estonia FI FR DE EL HU IE IT Latvia LT LU MT ND HR PL PT RO SK SIoveniaES SE UK 0 1000 2000 3000 4000 5000 6000 7000 0 50 100 150 200 250 300 Percapitatotalhealthexpenditure(internationalPPP) Male amenable mortality Men AT BE BG HR CY CZ DK Estonia FI FR DE EL HU IE IT Latvia LT LU MT ND PL PT RO SK Slovenia ES SE UK 0 20 40 60 80 100 120 140 160 180 Female amenable mortality Women Source: Jonathan Cylus using GHED and WHO Mortality database, 2015 Lower spending on health leads to worse health outcomes Higher spending improves health outcomes up to a point
- 5. 0 5 10 15 20 25 30 Slovenia Netherlands Austria Malta UnitedKingdom Spain Denmark CzechRepublic Luxembourg Slovakia Sweden Germany Ireland Lithuania Portugal Belgium France Finland EU28 Hungary Cyprus Croatia Estonia Poland Romania Italy Greece Bulgaria Latvia % Poorest Average Richest Unmet need is an indicator of insufficient spending and ineffective policies Unmet need for a medical examination for financial or other reasons by income groups in the European Union, EU-SILC data for 2013
- 6. Households not protected against the cost of ill health Impoverishing health expenditure Catastrophic health expenditure
- 7. Why more public and less out-of-pocket spending on health?
- 8. Countries with higher OOPs have more catastrophic spending Czech Republic Estonia Georgia Greece Ireland Latvia Moldova Portugal Slovenia R² = 0.44 0 2 4 6 8 10 12 14 16 18 0 10 20 30 40 50 60 70 %populationwithcatastrophicspending OOPs as % of total spending on health Source: WHO 2015 But policies matter too! Where OOPs are <15% of total health spending, very few households experience catastrophic spending Cyprus
- 9. Weak financial protection of the health system leads to more poverty 0% 2% 4% 6% 8% 10% 12% 14% 16% MDA 2013 LVA 2013 GEO 2014 POR 2010 LTU 2012 GRC 2013 EST 2012 CZE 2012 IRE 2009 SVN 2012 Further impoverished Impoverished At risk of impoverishment Catastrophic OOPs Source: WHO Barcelona Office for Health Systems Strengthening 2016 Incidence of catastrophic and impoverishing out-of-pocket payments (OOPs) in Europe
- 10. Distribution matters: the poorest households are consistently at greatest risk – important note for policy responses 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% SVN2007 IRL2009 CZE2009 CYP2009 GRC2008 LVA2008 EST2007 PRT2005 LTU2008 1 (poorest) 2 3 4 5 (richest) Source: WHO 2015 Consumption quintiles:
- 11. Monitoring financial protection over time in Latvia: Putting the analysis in context of policy changes 10.0% 10.1% 10.6% 12.9% 0% 2% 4% 6% 8% 10% 12% 14% 2008 2009 2010 2013 Shareofhouseholds At risk of impoverishment after OOPs Impoverished after OOPs Further impoverished after OOPs Catastrophic OOPs Source: WHO Barcelona Office for Health Systems Strengthening 2016 Co-payment exemptions discontinued for the poor in 2011
- 12. Catastrophic spending is primarily due to co-payments for medicines in Latvia: consistent with findings in most countries 0 10 20 30 40 50 60 70 80 90 100 1 (poorest) 2 3 4 5 (richest) Inpatient care Diagnostic tests Dental care Outpatient care Medical products Medicines Source: WHO Barcelona Office for Health Systems Strengthening 2016
- 13. More public spending means lower burden on patients, but policies matter Source: WHO estimates for 2012, selected countries with population > 600,000 More public spending and better health policies 15% 6%
- 14. 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 France UK Luxembourg Croatia Slovenia Germany Denmark Norway Sweden CzechRep Austria Iceland Ireland Belgium Finland Estonia Italy Slovakia Poland Spain Hungary Switzerland Portugal Israel Malta Lithuania Greece Latvia RussianFed Cyprus Turkey Romania Bosnia&Herz Belarus Turkmenistan Serbia TFYRM Montenegro Bulgaria Kazakhstan Albania Azerbaijan Moldova Kyrgyzstan Uzbekistan Ukraine Armenia Georgia Tajikistan Out-of-pocket payments (OOPs) as a % of total spending on health (high, upper-middle and lower-middle income countries) Source: WHO data for 2014 Danger zone >30% Warning 15-30% Safe <15%
- 15. Source: WHO data for 2012 0% 2% 4% 6% 8% 10% 12% Azerbaijan Turkmenistan Georgia Tajikistan Armenia Kazakhstan Albania Uzbekistan Cyprus Latvia RussianFed Belarus Romania Ukraine Bulgaria Kyrgyzstan Montenegro TFYRMacedonia Israel Turkey Poland Lithuania Estonia Hungary Ireland Moldova Slovakia Croatia Portugal Greece Serbia Slovenia CzechRepublic Finland Switzerland Bosnia&Herz Spain Italy Norway UK Sweden Belgium Germany Austria France Denmark Netherlands GeneralGovernmentHealthExpenditure(%GDP),2012 Public spending on health as a share of GDP WHO/EUROPE countries with population > 600,000 (2012) 0% 2% 4% 6% 8% Low & lower-middle income Upper-middle income High income Minimum 6% for good financial protection (provided that strong pro-poor policies are also in place)
- 16. Accounting for public spending on health: the equation and a simple illustration Gov’t health spending GDP = Total gov’t spending GDP X Gov’t health spending Total gov’t spending Fiscal context Public policy priorities Government health spending as share of the economy 6% 12-15%40-50%
- 17. Priority to health in public spending: a political choice Share of health spending within government budget (high, upper-middle, lower-middle and low income) 0 2 4 6 8 10 12 14 16 18 20 22 Cyprus Latvia RussianFederation Israel Poland Greece Estonia Bulgaria Finland Ireland Portugal Lithuania Slovenia SanMarino Malta Luxembourg Italy CzechRepublic Slovakia Belgium Spain Croatia Sweden Iceland France UnitedKingdom Denmark Austria Norway Monaco Germany Netherlands Switzerland Azerbaijan Turkmenistan Albania Montenegro Hungary Kazakhstan Romania Turkey Belarus Serbia TFYRM BosniaandHerzegovina Georgia Armenia Uzbekistan Ukraine Kyrgyzstan RepublicofMoldova Tajikistan Source: WHO Global Health Expenditure Database for 2012 Minimum 12%
- 18. Share of health within government budgets over time: a widening gap Source: WHO NHA database, 2012 14.4%13.7%
- 19. Spending on health and financial protection: why and how? Conclusions
- 20. Why? Some starting points Improve health outcomes Reduce poverty due to ill health Break the vicious cycle between poverty and ill health Improve economic and social development
- 21. How? Some key indicators Aim for reducing OOPs to 15% of THE - Focus on medicines: the single most important factor for catastrophic expenditure 0% impoverishment - Focus on the poor and pensioners Aim for at least 6% of GDP public spending on health Allocate minimum 12% of government spending to health 15% 0% 6% 12%
- 22. Universal health coverage (UHC) All people should get access to needed health services of sufficient quality to be effective (incl. prevention, promotion, treatment, prescription medicine, rehabi- litation and palliative care) without the risk of being exposed to financial hardship
- 23. Our vision in WHO is a Europe free of impoverishing out-of-pocket payments 0% A vision that originates from the Tallinn Charter
- 24. WHO Barcelona Course on Health Systems Strengthening for Improved TB Prevention and Care 13-19 October 201624 WHO Barcelona Office for Health Systems Strengthening Established in 1999 Supported by the Government of the Autonomous Community of Catalonia, Spain Focuses on health systems strengthening and financing: analysis and capacity building Staff work directly with Member States across the European Region Part of the Division of Health Systems & Public Health of the WHO Regional Office for Europe www.euro.who.int Contact us: Sant Pau Art Nouveau Site Nostra Senyora de La Mercè pavilion Sant Antoni Maria Claret 167 08025 Barcelona, Spain Email: eubar@who.int