WHO-EM/HEC/011/E
Report on the
Health care financing policy consultative meeting
Cairo, Egypt 13–17 November 2005
World Health Organization Regional Office for the Eastern Mediterranean
WHO-EM/HEC/011/E
Report on the
Health care financing policy consultative meeting
Cairo, Egypt 13–17 November 2005
World Health Organization Regional Office for the Eastern Mediterranean Cairo 2006
© World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 670 2535, fax: +202 670 2492; email: DSA@emro.who.int). Requests for permission to reproduce WHO EMRO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to the Regional Adviser, Health and Biomedical Information, at the above address (fax: +202 276 5400; email HBI@emro.who.int). Document WHO-EM/HEC/011/E/04.06/100
CONTENTS 1. 2. INTRODUCTION .............................................................................................................1 TECHNICAL PRESENTATIONS ....................................................................................2 2.1 Health care financing in the Region: policy options – an introduction....................2 2.2 Designing health financing systems to reduce catastrophic health expenditure ......3 2.3 Community-based health insurance .........................................................................4 2.4 Social health insurance – reaching universal coverage via social health insurance ..................................................................................................................5 2.5 Tax-based financing .................................................................................................6 2.6 Overview of provider payment methods..................................................................7 2.7 Contracting out publicly financed health services: experience from the Region.....7 2.8 Catastrophic expenditure, poverty impact and health utilization: concepts and implications of financial risk protection for health financing function....................8 2.9 Introduction to health insurance simulation model (SimIns) ...................................9 2.10 Costing methods and application ...........................................................................10 COUNTRY PRESENTATIONS ......................................................................................10 PANEL DISCUSSION: CONCLUSIONS ......................................................................12 RECOMMENDATIONS .................................................................................................13
3. 4. 5.
Annexes 1. AGENDA ........................................................................................................................14 2. PROGRAMME ...............................................................................................................15 3. LIST OF PARTICIPANTS ..............................................................................................17
WHO-EM/HEC/011/E 1. INTRODUCTION
A health care financing policy consultative meeting was organized on 13–17 November 2005 in Cairo, Egypt, by the World Health Organization (WHO) Regional Office for the Eastern Mediterranean (EMRO). The objectives were to: • • • • discuss recent developments in health care financing including the 58th World Health Assembly resolution on social protection; discuss payment mechanisms and different methods of costing; acquire necessary skills to measure catastrophic health expenditure and fair financing index; and use a simulation model aimed at assessing trends in health care services.
The meeting was attended by health policy-makers and health financing experts from Bahrain, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Pakistan and Tunisia, and by WHO staff from headquarters and the Regional Office. The agenda, programme and list of participants are attached as Annexes 1, 2 and 3, respectively. The meeting was opened by Dr Mohamed Abdi Jama, Deputy Regional Director, who delivered a message from Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. In his message, Dr Gezairy noted that financing was one of the functions of health systems, and that its improvement was of paramount importance in increasing health system performance. Indeed, most health sector reforms were related in one way or another to health care financing. Health systems were faced with inequities in health care financing, with limited coverage by prepayment schemes and an increasing share accounted for by direct, or out-of-pocket, spending. The percentage of households facing disproportionately high health expenditure was estimated to be about 4% in the Eastern Mediterranean Region, and the share of direct payment on health was over 50% in most countries of the Region. The high level of out-of-pocket payment, and the lack of development of prepayment schemes in countries of the Region to cover all citizens and residents, had long been concerns of the Regional Office. He closed by expressing the hope that the analytical tools developed by WHO which would be presented to participants during the meeting would be of assistance in helping them to develop policies that were right for their countries. The meeting was structured into technical presentations, discussions and training sessions. The first two days of the meeting were given to technical presentations on health financing options, focusing on policy options that can help reduce out-of-pocket expenditure (payments that must be made by the patient at the point of receiving a service and which will not be reimbursed). Topics covered included community-based health insurance and social health insurance, tax-based financing and purchasing functions (provider payment methods). On the third day, participants working on technical matters were given a training session on different tools for health financing policy design in the computer laboratory. Participants more involved in policy-making made a field visit to learn about the health sector reform in Egypt. On the fourth day participants were introduced to the health insurance simulation model SimIns and given an opportunity to use it in a laboratory setting. On the last day country teams presented the main features of health financing in their respective countries, using the
WHO-EM/HEC/011/E Page 2 tools that had been presented throughout the week. The meeting concluded with a panel discussion. 2. 2.1 TECHNICAL PRESENTATIONS Health care financing in the Region: policy options – an introduction Dr Belgacem Sabri
Presentation There are a number of issues and concerns which all countries have in common when it comes to health financing, such as equity, efficiency, poverty and social exclusion. Specific issues and challenges faced by countries can vary with socioeconomic level. Low-income countries in the Region, for instance, suffer from under-funded health systems, limited social health insurance coverage, high rates of out-of-pocket expenditure and a lack of community health insurance schemes. Middle-income countries seem to be suffering from inappropriate and inefficient allocation of resources and varying levels of health insurance coverage. Highincome countries are more concerned with issues of cost containment and equity for expatriates. There is little knowledge about health financing in the Region, along with limited capacity in health care financing analysis and a lack of clear policy objectives. Most health financing policy reforms focus on improving equity, efficiency and responsiveness. The kind of health care financing reform needed by different countries also depends on their background. For example low-income countries spend much energy trying to increase funding and seeking different ways to finance health systems such as social health insurance or community-based insurance while high-income countries are more likely to be interested in issues such as the rational use of medical technologies. In conclusion, the need for reform is clear; WHO support in this area is available for countries, especially with regard to capacitybuilding and technical expertise. Discussion During the discussion, it was emphasized that social health insurance is a tool, not a goal in itself. The questions to raise are: why is there a need for reform? Is out-of-pocket expenditure a real problem? If the answer to the last question is yes, the different options have to be carefully considered. Some countries may have no particular interest in abandoning their tax-based health financing system. However, many participants from low- and middle-income countries said that their country was suffering from under-financing, and wondered whether health insurance was a solution to their problem. It was emphasized that social health insurance must be implemented at a reasonable pace, beginning with a small, realistic benefit package and some co-payment. In most of the countries of the Region, out-of-pocket expenditure is a heavy burden on households that pushes many into poverty every year. It was also pointed out that many determinants of health
WHO-EM/HEC/011/E Page 3 are outside the reach of health care financing policy-makers. These include social determinants such as education, sanitation and access to safe water. 2.2 Designing health financing systems to reduce catastrophic health expenditure Dr Ke Xu
Presentation A household’s health expenditure is defined as catastrophic when the medical bills of one or more of its members are high enough to force the family to reduce its expenditure on other necessities for a period of time. It is estimated that 100 million people are pushed below the poverty line every year because of health expenditure. After looking at evidence from 90 countries, it has been found that the following factors and circumstances may increase the likelihood of catastrophic expenditure: when total health expenditure is a large proportion of Gross Domestic Product (GDP); when out-of-pocket expenditure is a large proportion of total health expenditure; and when there is a high percentage of the population living below the poverty line. Many countries in the Region rely heavily on out-of-pocket payments when it comes to health care expenditure. Health systems rely on out-of-pocket expenditure when government spending on health is insufficient and when voluntary prepayment schemes are very limited. Health financing systems can offer to address this problem by reducing out-of-pocket expenditure by increasing prepayment schemes, and by strengthening health financing functions (revenue collection, pooling, purchasing). In May 2005, the Health Assembly issued a resolution (WHA58.33) on sustainable health financing, universal coverage and social health insurance in which it urged Member States to ensure that health-financing systems include a method for prepayment of financial contributions for health care with a view to sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care. Discussion It was pointed out that in the Islamic Republic of Iran, catastrophic expenditure is high despite the high rate of health insurance coverage. This was mainly caused by providerinduced demand. The discussion therefore focused on the ways to contain costs in a health insurance context. In the case of provider-induced demand, tough measures must be introduced. Many health insurance schemes have tools to detect physicians who over-prescribe. The problem of physicians working in both public and private sectors was also raised. Despite the harmful consequences on health systems, it was very difficult to tackle this problem: public providers who are forbidden to have a private practice can simply choose to abandon the public sector and work only in the private, thereby exacerbating the phenomenon of passive privatization. In conclusion it was agreed that extending prepayment and moving towards universal
WHO-EM/HEC/011/E Page 4 coverage were good solutions to the issue of catastrophic health expenditure but require a strong administration and commitment among the top leadership. 2.3 Community-based health insurance Mr Ole Doetinchem
Presentation Community-based health financing is a mechanism whereby households in a community finance the costs of health services and participate in the management of this financing scheme and the organisation of health services. It is a form of prepayment and one of the tools available to reduce catastrophic expenditure. The WHO conceptual framework for analysis (from The World Health Report 2000) shows the relationship between health system function, including health financing function and the goals of the health system. He used this framework to assess performance of community-based health insurance in the following ways: • • • Revenue collection can be assessed through enrolment and through ratio of prepaid contribution to health care costs. Pooling can be assessed through practice of risk-pooling across different groups in the community. Purchasing can be assessed through practice of strategic purchasing.
These criteria were studied by WHO in a 1998 study, which showed that in spite of strong heterogeneity, existing community-based health insurance performance was rather weak. This led Mr Doetinchem to conclude that community-based health insurance is a good concept, but has weak foundations in practice (low enrolment, low risk-pooling, weak financial and managerial capacity and so on). Its strengths are in involving the community in health service provision, thereby improving their responsiveness to local needs. Communitybased health insurance can also serve as a first step to reorganize financial flows into prepayment schemes, which then later need to be enlarged or linked for increased risk-pooling and financial sustainability. Like all prepayment mechanisms, such schemes are supported by WHO, but their success depends on many factors such as government commitment to support these schemes, including possibly re-insuring them to protect them against large losses. Discussion During the discussion participants agreed that community-based health insurance is a good instrument which enables health systems to reach populations that have never been reached before. However, the instrument suffers from the same difficulties as other insurance schemes, and more. Moreover, there are some necessary prerequisites to the implementation of community-based health insurance schemes, for instance the pre-existence of other community activities which act as a form of insurance. Another problem is that communitybased health insurance does not achieve a high rate of risk pooling. Adverse selection is a major problem for this type of health insurance. Other prepayment schemes such as social health insurance share risk between the healthy and the sick – and between the rich and the
WHO-EM/HEC/011/E Page 5 poor. In community-based health insurance schemes risks are shared between the healthy and the sick – but between the poor and the poorest. It was agreed that government support was essential, to support training in the skills needed for the development of schemes. Governments could also re-insure the schemes, which would provide much-needed financial security. In the final part of the discussion, the Regional Adviser for Community-Based Initiatives focused on the importance of the participation of communities when defining the benefit package and in the management of the scheme. Evidence provided by studies commissioned by the Regional Office in Pakistan and Sudan showed the importance of trust and goodwill for the success of community-based health insurance schemes. 2.4 Social health insurance – reaching universal coverage via social health insurance Dr Guy Carrin
Presentation The problem of catastrophic expenditure can also be addressed by strengthening prepayment through social health insurance. The presentation outlined the different ways in which a social health insurance scheme could be designed. There are many components of the design ranging from population coverage and extent of prepayment to the composition of the benefit package and the different methods of provider payment. The different stakeholders in a social health insurance scheme are beneficiaries, enterprises, providers, and governments. The presentation analysed their roles, as well as their strategies and interests. Key components and stakeholders were illustrated using examples from selected social health insurance schemes from all over the world. There is no single way of achieving universal coverage; many options exist, one of which is social health insurance. There are even several variants of social health insurance. Discussion The discussion addressed several aspects of the key design components. First, participants asked for some comment on the relationship between social health insurance and community-based insurance. Dr Carrin explained the advantages of an overall umbrella approach, in cooperation with a national health agency, in order to make sure that an appropriate level of cross-subsidization is reached. Participants then discussed the appropriate level of per capita at which to launch social health insurance, particularly in countries where there is a large informal sector. Finally, the problem of multiple stakeholders was raised: it is very difficult to monitor a system where many interests (workers, employers, providers and so on) are present. This is why a consensus must always be sought in advance. Dialogue between different actors must be enhanced.
WHO-EM/HEC/011/E Page 6 2.5 Tax-based financing Dr Ke Xu
Presentation Tax-based financing was the third prepayment instrument discussed. In theory, taxbased financing could be a progressive method of raising funds and meeting people’s needs, but it requires stable and growing government revenue, progressive income tax policy and transparency in public health financing. In practice, its performance varies dramatically depending on a country’s social, economic, political and cultural background. This is why the tax-based financing approach should be seen as only one of many ways to finance health care. There is no evidence to suggest that tax-based financing inherently performs better, in terms of health financing functions, than social health insurance or the other way round. Different types of systems work well in different contexts. During the transition to universal coverage, various types of prepayment schemes need to be encouraged, so as to systematically enhance financial protection. The choice of method used – whether tax-based, social health insurance or a mix of financing systems – will be determined by a country’s economic, political and social context.Discussion The discussion focused on the question of how best to implement a tax-based health financing system. Participants wanted to know whether there were some necessary prerequisites to implementation of tax-based schemes, whether it was more efficient and more equitable than social health insurance, and whether methods were available to improve its performances. It was emphasized that both tax-based financing and social health insurance were instruments to be employed to achieve a single goal: universal coverage. Differences between the two systems were not as great as often thought: various ways to fulfil health financing functions were shared by both mechanisms. It was also reiterated that country context is important, and that no standard solution would be most effective in every single country. Choosing the most suitable financing option requires an understanding of a country’s characteristics, history and traditions. During the transition period to universal coverage, WHO supports every movement towards development of prepayment schemes.
WHO-EM/HEC/011/E Page 7 2.6 Overview of provider payment methods Dr Hossein Salehi
Presentation The presentations for the remaining sessions focused on improving health care financing by improving the purchasing function. Health care financing aims to generate sufficient financial resources and to use those which are in existence efficiently, equitably and in a manner which is sustainable. The relations between the different agents (namely providers, consumers/patients and third party payers) of health systems can become obscured by information problems. Often information is ‘asymmetric’, for instance providers may have significantly more information and knowledge than patients. This can lead to underperformance of the health system and to increasing costs. Therefore it is important that provider payment methods aim to contain costs and improve allocative efficiency (produce the ‘right thing’) and technical efficiency (produce the right thing in the ‘right way’) in order to improve provider performance. Different provider payment modalities include fee-for-service, per diem, case-mix and capitation (flat rate for predefined benefit package). In moving from fee-for-service to capitation, the risk for the provider increases as the risk for the payer decreases. The choice between the different methods should be made according to the country’s and the service specificities. It is important to avoid passive purchasing, and to practise strategic purchasing that aims to improve health systems’ performance in terms of efficiency, access, equity, quality and monitoring. As well, administration and monitoring of each modality requires the development of an appropriate health information system. Discussion During the discussion, participants emphasized that there is no tool able to perform the purchasing function perfectly; a combination of tools should be used, tailored to a particular country’s background and situation. In some cases, it is beneficial to move to case-based payment or capitation; however these modalities need strong monitoring capabilities in order to control potential abuse of the system by providers, protect the patients and contain costs. Like health financing, provider payment modalities are tools. Focus should be on efficiency, access, equity, and cost-containment. Mixed approaches should be used. It is important to make sure that providers will accept whichever combination is decided upon and that the system is managed efficiently. 2.7 Contracting out publicly financed health services: experience from the RegionDr Sameen Siddiqi
Presentation Contracting is a possible purchasing mechanism which can help achieve public policy objectives. There are different types of contracting with different rationales. A study was
WHO-EM/HEC/011/E Page 8 conducted in 10 countries of the Eastern Mediterranean Region which aimed to explore the nature and extent of factors affecting contracting in the health sector. The study showed that contracting is being increasingly used to purchase publicly financed health services in the Region, for non-clinical, hospital services or primary health care services. Contractual arrangements can be public–private or public–public. Contracting can be motivated by national policies aiming to move towards free market, privatization and globalization. It might also be encouraged by donor agencies seeking to promote access, coverage and efficiency. Some ministries of health continue to see contracting as a tool that promotes privatization, but other ministries of health have realized that contracting can enable better monitoring of the private sector. However, contracting requires high capacity for monitoring, which is generally low in the Eastern Mediterranean Region.Discussion Participants shared their experiences of contracting in their own countries. Most participants said that the success of the contracting process was largely dependent on the capacity and cooperation of the private sector. For example, in Bahrain the main problem was that the private sector is not ready to contract; it does not have the bed capacity to deal with the activities public facilities would like to outsource. In Lebanon, the problem is quite the opposite: the private sector is prominent and powerful, and the Ministry of Public Health is unable to regulate it. In Jordan, the situation is different again: the private sector is very developed but its hospital occupancy rate is very low. In such a context, contracting may be an effective way to improve efficiency. 2.8 Catastrophic expenditure, poverty impact and health utilization: concepts and implications of financial risk protection for health financing function Dr Ke Xu
Presentation A health system is fairly financed if the household contribution to the health system depends on household income, independent of the household’s health status or use of the health system. That is to say when high-income households pay more than low-income households, when households with the same income pay the same amount, when no household faces financial hardship and when no household is impoverished as a result of health expenditure. The simplest indicator of fairness in health financing is the number of households facing catastrophic expenditure (when out-of-pocket expenditure on health care equals or exceeds 40% of household’s non-subsistence spending). Catastrophic expenditure induced by high medical bills can push some household’ into poverty or stop people from seeking care at all. In order to assess financial risk and fairness, various kinds of information are needed. The following questions must be posed: who needs and who uses health services? Who pays? How much and for what kinds of services? What is the impact of the payment on a household
WHO-EM/HEC/011/E Page 9 (such as catastrophic expenditure)? What is the impact of the payment on poverty? Who suffers severe financial burden by paying for health services? The idea of financial risk protection was illustrated using the example of a study on abolition of user fees in Uganda. This study shows that the abolition of user fees improved access to health services among the poorest of the population. However, it does not protect them from facing catastrophic expenditure.Discussion The discussion at first focused on the technical aspects of the presentation, mainly the definition and the consequences of choosing a particular definition. Participants asked how to identify and target those people who have been pushed into poverty because of health expenditure. This information can be inferred from statistical analysis; for example, the analysis might suggest that female-headed households are more likely to face catastrophic expenditure. It is also possible to focus on criteria other than income: for example geographical location or age may also be good indicators of the probability of facing catastrophic expenditure. 2.9 Introduction to health insurance simulation model (SimIns) Dr Guy Carrin and Mr Ole Doetinchem
SimIns is a software tool designed to analyse the financial aspects of policy initiatives at the macro-level, including the impact of introduction or expansion of social health insurance on the health financing system as a whole. SimIns can: • • • Illustrate different policy options with respect to key health insurance variables (not setting policies) Facilitate search for financial equilibrium: which sets of contributions and/or utilization patterns and/or health care costs are compatible with this goal Examine the impact of health insurance on the overall structure of national health financing and on the structure of public finances.
This tool can be used for focusing either on the financial development of a specific health insurance, such as a community-based health insurance (in this case, the basic version of SimIns is sufficient) or on the financial development of health insurance within a larger, nationwide context, for example social health insurance (in this case, the SimIns Plus version is needed). The presenters emphasized that SimIns is not a tool for day-to-day management of health insurance. Neither is it a behavioural model forecasting agents’ response to health policies. After this presentation, a detailed demonstration of each step of the use of the software was performed on sample data from an imaginary country.
WHO-EM/HEC/011/E Page 10 2.10 Costing methods and application Dr Taghreed Adam Presentation Dr Taghreed Adam presented to participants involved in policy-making how cost information could be used to improve health financing functions such as pooling, purchasing and provider payment methods. She first of all focused on how to prioritize interventions: regardless of the financing scheme, criteria for priority-setting should be used to select the best mix of interventions to include in a basic benefits package. Cost effectiveness – which relates costs of health care interventions to health gains – is a criterion which can help in making these decisions or choices. Several cost–effectiveness studies were presented to demonstrate how they can be a powerful tool to help choose between interventions. The appropriate choice, however, cannot be made purely on the grounds of cost-effectiveness: equity, for example, must also be considered. Cost–effectiveness studies can also be used to choose between the different provider payment modalities: cost per case (using diagnosis-related groups), cost per capita, fee-forservice. However, variability in costing methods makes it very difficult to compare the results of different studies, diminishing their usefulness outside their own particular setting and context. Discussion The discussion first highlighted the importance of promoting these tools and training staff on how to use them. It was pointed out that ownership of the tools is extremely important, and that the purpose of using the tools should not be forgotten: cost-effectiveness is a tool to facilitate the decision making process; it is not the decision itself. It is very important to ensure that a good dialogue is established between economists and policy-makers. The case of DRGs (diagnosis-related groups) was used to illustrate successful ‘ownership’ of a tool. Many countries consider DRGs a highly complex but very useful tool for their health systems, regardless of the fact that it was first developed in the North American context. 3. COUNTRY PRESENTATIONS
Bahrain Concerns with health financing in Bahrain are not, unlike most of the countries present at the meeting, dominated by out-of-pocket expenditure: 65.5% of total health expenditure is borne by the government or by pension funds. The main challenges Bahrain faces are linked to the rise in healthcare demand and costs and to the sustainability of public financing based
WHO-EM/HEC/011/E Page 11 on oil revenue in the future. Another issue is the capacity of the Ministry of Health, which is simultaneously involved in too many activities. This is why Bahrain is initiating reform focusing on training, capacity building and the introduction of new tools such as the ones presented during the week. Egypt Egypt has both governmental and nongovernmental health care financing and provision. Over 60% of total health expenditure is financed by out-of-pocket payments. Tax-based financing and social health insurance coverage of specific groups covers the rest. Programmes are being developed in order to achieve universal coverage. The country currently has high levels of catastrophic health expenditure (high rate of out-of-pocket expenditure, 17% of the population below the poverty line, total health expenditure amounting to over 5% of GDP). Islamic Republic of Iran In the Islamic Republic of Iran, 52% of total health expenditure consists of out-ofpocket spending, even though over 75% of the population is covered by health insurance. In 2002, more than 2% of households faced catastrophic expenditure, and more than 1% were impoverished because of catastrophic expenditure. To tackle this problem, the Islamic Republic of Iran introduced an article in its 4th national 5-year development plan stating the following objectives: reduction of out-of-pocket expenditure to less than 30% by 2009; and improvement of the Index of Fairness in Financial Contribution (IFFC) to 0.9 by 2009. A remarkable increase in health budget for the current fiscal year was voted by Parliament. Support is needed from WHO in the use of new tools. Jordan Total health expenditure in Jordan amounts to more than 10% of GDP. 58% of this is private expenditure. The civil insurance programme covers 31% of the population and 26% are covered by the military insurance programme. Private funds insure 8.8% of the population. Jordanian participants explained that they need the assistance of WHO in several fields: building capacity in health care financing including SimIns software, which will help to analyse the impact of increasing national health insurance coverage; and reducing high expenditure on health in Jordan by formulating policies, strategies and plans of action. Lebanon With a total health expenditure amounting to 12% of GDP and out-of-pocket payments exceeding 60% of total health expenditure, Lebanon faces high risk of catastrophic expenditure. Many schemes belonging to different ministries cover the population. The current challenge of the Ministry of Public Health is to unify them under the National Social Security Fund. The aim is to achieve coverage for all Lebanese by extending coverage to new groups and reducing out-of-pocket spending. Particular attention is being paid to monitoring and regulating providers.
WHO-EM/HEC/011/E Page 12 Morocco Total health expenditure in Morocco is also dominated by out-of-pocket expenditure (51.8% of the amounts to 5% of GDP). A high percentage of this expenditure is dedicated to purchasing medicines. Health insurance only pays for 16% of total health expenditure. It is estimated that 1.3% of the population sell their assets or borrow in order to pay for health care services. The government is working to establish a medical assistance programme for the poor population. Health insurance coverage is likely to increase to 34% of population because social health insurance recently became mandatory for everyone working in the formal sector. Pakistan Pakistan’s population is young, growing and mostly poor. Health expenditure in this country is on the rise, and very high numbers of health workers (for example, 175 000 physicians and 40 000 nurses) will be needed by the year 2010. Allocative efficiency is very low. At the macro level, several reforms are needed, beginning with a health policy review and a national health accounts study, to know what resources are available, who provides them, and how they are spent. Tunisia In Tunisia, more than half of health expenditure is borne by households despite the fact that two-thirds of the population is covered by health insurance schemes. The health insurance coverage is limited to public and private sector formal employees. Total health expenditure is rising, and most of the increase is borne by households. In order to mitigate the high level of out-of-pocket expenditure and its consequences and to improve quality of services, the government is establishing a single basic compulsory scheme called National Health Insurance Fund. In parallel, the government is also setting up an optional scheme administered by private insurance companies and private funds in order to improve services and reduce out-of-pocket payments. 4. PANEL DISCUSSION: CONCLUSIONS
During the panel discussion, participants noted the need for more knowledge of economics and for more training for health economists in countries. Ministry of Health personnel also need to seek out economic expertise in other sectors within their own countries. The need to strengthen and extend financial protection was highlighted. In the transition to universal coverage, all forms of prepayments have to be encouraged. Countries could request advice and support from WHO in this field, and SimIns software would soon be available to help the decision-making process. It was agreed that concern about health care financing was growing, and that more data are needed to increase efficiency of policies. In order to improve health policy-making,
WHO-EM/HEC/011/E Page 13 capacity needs to be strengthened in partnership with all actors involved in the health sector. Finally, participants noted the usefulness of the meeting and the need to continue sharing different experiences in the field. 5. 1. RECOMMENDATIONS Ministries of health should seek economic expertise in other ministries and in academic and non-academic national institutions in order to develop and strengthen health economics capacity in their countries. Ministries of health should collect more data for use in health financing policy decisions, such as through conducting household surveys and national health accounts exercises, with support from their statistical institutions and WHO as necessary. WHO should organize more training activities to build the capacity of health economists in countries of the Region. WHO should establish a regional network of people working in or concerned with health care financing to facilitate exchange of experience and expertise.
2.
3.
4.
WHO-EM/HEC/011/E Page 14 Annex 1 AGENDA • Health financing policy options to reduce out-of-pocket payment and catastrophic expenditure – Community-based health insurance – Social health insurance – Tax-based financing Purchasing function: provider payment mechanism Catastrophic expenditure Field visit for health policy-makers /training on measuring and analysing catastrophic expenditure for technical team Introduction to simulation model (SimIns) Country presentations and health care financing issues: the way forward
• • •
•
•
WHO-EM/HEC/011/E Page 15 Annex 2 PROGRAMME Sunday, 13 November 2005 08:00–08:30 08:30–09:00 Registration Opening session Message from the Regional Director Introduction of the participants Objectives of the meeting (Dr Hossein Salehi) Health financing policy options: an introduction Universal coverage: policy options for the development of health financing systems (Dr Belgacem Sabri) Discussion Designing health financing systems to reduce catastrophic health expenditures (Dr Ke Xu) Discussion Health financing system and health financing functions application Community-based health insurance (Dr Ole Doetinchem) Discussion Social health insurance (Dr Guy Carrin) Discussion
09:00–10:30
10:30–13:30
13:30–15:30
Monday, 14 November 2005 08:30–10:30 10:30–13:30 Tax-based financing (Dr Ke Xu) Discussion Purchasing function in health financing: Overview of provider payment methods (Dr Hossein Salehi) Discussion Catastrophic expenditures, poverty impact and health services utilization Concepts and implications of financial risk protection for health financing functions (Dr Ke Xu) Application of methodology and data requirements (Ms A. Mylena Aguilarrivera)
13:30–17:00
Tuesday, 15 November 2005 Group one Field visit to observe Health Sector Reform, Egypt Group two (in the computer laboratory) Tools for health financing policy design Data analysis using prepared datasets (Dr Ke Xu and Ms A. Mylena Aguilarrivera)
08:30–16:00 08:30–13:30
WHO-EM/HEC/011/E Page 16 13:30–15:30 15:30–17:00 Interpretation of results–Group work Group presentation
Wednesday, 16 November 2005 08:30–10:30 Health insurance simulation model (SimIns) (Dr Guy Carrin and Dr Ole Doetinchem) Introduction to SimIns: Summary and demonstration on User guide; a comprehensive look User guide (Dr Guy Carrin and Dr Ole Doetinchem) Discussion Key policy issues at country level Group one (Purchasing function in health financing) (cont’d) Costing: methods and applications (Dr Taghreed Adam) Group two (Tools for health financing policy design) Using SimIns: analysing practical cases (Dr Guy Carrin and Dr Ole Doetinchem)
10:30–13:30 13:30–17:00
Thursday, 17 November 2005 08:30–13:30 13:30–15:30 Country presentation Health care financing issues: the way forward Panel discussion Summary and conclusions Closing session
15:30 -16:30
WHO-EM/HEC/011/E Page 17 Annex 3 LIST OF PARTICIPANTS BAHRAIN Dr Fawzi A. Amin Assistant Undersecretary Training and Planning Ministry of Health Manama Dr Lameeah Al Tahoo Chief of Planning Office of Plans and Programs Ministry of Health Manama Ms Sawsan A. Hussain A. Jaleel Health Economist Office of Plans and Programs Ministry of Health Manama
EGYPT Dr Alaa Ghannam Ministry of Health and Population Cairo Dr Soad Abd El Megeed Ministry of Health and Population Cairo Dr Isaac Naguib Ministry of Health and Population Cairo
ISLAMIC REPUBLIC OF IRAN Dr Farid AboulHassani Assistant Professor for Internal Medical Sciences University of Medical Sciences Ministry of Health and Medical Education Teheran
WHO-EM/HEC/011/E Page 18 Mrs Fatemeh Khanem Saberi Safaei Statistical Centre of Iran Teheran
JORDAN Dr Jamal Abu Saif High Health Council Amman Mr Ali Madani Royal Medical Services Amman Dr Mamoun Maghyereh Director of Health Insurance Ministry of Health Amman
LEBANON Mrs Hilda Harb National Health Accounts Project Ministry of Public Health Beirut Dr Layla Al Harb National Social Security Fund Beirut
MOROCCO Mr Abdel Jaouad Ezzrari Economist Observatoire des Conditions de Vie de la Population Direction de la Statistique Rabat Ms Asma El Alami El Fellousse Chef de Service de l’Economie Sanitaire DPRF Ministere de la Sante Rabat
WHO-EM/HEC/011/E Page 19 PAKISTAN Mrs Noshin Hussain Research Associate National Health Policy Unit Ministry of Health Islamabad
TUNISIA Professor Noureddine Achour Directeur de l’Institut de Sante Publique Tunis Dr Chahed Mohamed Kouni Researcher Health Financing Institut de Sante Publique Tunis Mr Abdelmajid Jabri Chef de Service Caisse Nationale d’Assurance Maladie Tunis WHO Secretariat Dr Mohamed Abdi Jama, Deputy Regional Director, WHO/EMRO Dr Belgacem Sabri, Director, Health Systems and Services Development, WHO/EMRO Dr Hossein Salehi, Regional Adviser, Health Economics, WHO/EMRO Dr Sameen Siddiqi, Regional Adviser, Health Policy and Planning, WHO/EMRO Dr Mohamed Assai, Regional Adviser, Community-Based Initiatives, WHO/EMRO Dr Guido J.R. Carrin, Evidence and Information for Policy, WHO/HQ Dr Ke Xu, Evidence and Information for Policy, WHO/HQ Ms A. Aguilarrivera, WHO/HQ Mr O. Doetinchem, WHO/HQ Dr Taghreed Adam, Evidence and Information for Policy, WHO/HQ Dr Zine Eddine El Idrissi, Short Term Professional, WHO/EMRO Mrs Naglaa Salah, Secretary, WHO/EMRO