WPRlDHS/03IHCF(2)/2009
English Only
Report series number: RS/2009/GE/07(PHL)
REPORT STRATEGY ON HEALTH CARE FINANCING I REVIEW OF THE IN THE WESTERN PACIFIC REGION
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 27-28 April 2009
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western pacific Manila, Philippines June 2009 WHOJWI'RO LlBRARY MA,,'H .\. rmLlPl'TNES
1 7 SEP 2009
NOTE The views expressed in this report are those of the participants in the Review of the Strategy on Health Care Financing in the Western Pacific Region and do not necessarily reflect the policies of the World Health organization.
t
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for those who participated in the Review of the Strategy on Health Care Financing in the Western Pacific Region held in Manila, Philippines, from 27 to 28 April 2009.
CONTENTS SUMMARY I. 2. INTRODUCTION ............................................................................................................... 1 PROCEEDINGS ................................................................................................................. 2 2.1 2.2 2.3 2.4 2.5 2.6 Opening ceremony .............................................................................................. 2 Financial crisis and actions on monitoring and mitigating ................................ 2 possible impacts on health Midterm review and the health financing situation in Asia and the Pacific ....... 3 Health financing strategy for 2010-2015 ............................................................ 3 Proposed strategy areas and actions .................................................................... 4 Summary discussion and recommendations ....................................................... 4
ANNEXES: ANNEX I ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 ANNEX 7 ANNEX 8 ANNEX 9 AGENDA TIMETABLE LIST OF PARTICIPANTS OPENING SPEECH OF THE REGIONAL DIRECTOR IMPACT OF THE GLOBAL RECESSION ON THE POOR AND VULNERABLE IN ASIA WHO RESPONSE TO THE ECONOMIC CRISIS REGIONAL SURVEY OF HEALTH FINANCING HEALTH FINANCING ISSUES IN ASIA AN THE PACIFIC HEALTH CARE FINANCING STRATEGY: SEAR REVIEW THE HEALTH CARE FINANCING STRATEGY FOR 20 I 0-2015 HEALTH FINANCING STRATEGY AREAS AND ACTIONS SUMMARY OF DISCUSSIONS
ANNEX 10 -
Keywords: Delivery of health care - economics I Economic recession I Western Pacific
SUMMARY
A Review of the Strategy on Health Care Financing in the Western Pacific Region was held at the WHO Regional Office for the Western Pacific in Manila, Philippines from 27 to 28 April 2009. The objectives of the meeting were: (I) to re-examine the implementation of the Strategy on Health Care Financing for 2006--2010 based on the midterm review; to review the revised draft strategy on health care financing for 2010--2015 and propose (2) further changes according to global evidence relevant to universal coverage, specific country needs, and perspectives of the WHO South-East Asia Regional Office; and to provide recommendations for the revised regional strategy on health care financing for (3) 2010--2015. In late 2008, the WHO Regional Office for the Western Pacific commissioned a midterm review of the implementation of the Strategy on Health Care Financing in 14 countries in the Western Pacific Region that could offer lessons in how health financing and the Strategy might be improved. Based on the recommendations put forth, a new health fmancing strategy for 20 I 0--2015 was drafted that included five strategy areas focused on achieving universal coverage by country health systems. In late March 2009, a panel of experts from all WHO regions and most of the major donor organizations reviewed the proposed strategy in light of the midterm review and other global evidence. This panel afforded the opportunity to integrate and coordinate the regional strategy with global evidence and the perspectives and recommendations of other organizations. The draft strategy for 20 I 0--20 15 was revised accordingly, three strategy areas were added, and the revised draft was circulated to participants of this meeting.
Global evidence shows that catastrophic payments and impoverishment are high in countries with high out-of-pocket expenditure and low government health spending. The new strategy fits within the WHO framework of health system strengthening and follows a logical path towards universal coverage. Strategy targets or progress indicators were revised: (I) out-of-pocket spending should not exceed 300/0-40%; (2) total health spending should be at least 4%-5% of GDP, with 50%-70% of public fmancing; (3) over 90% of the population is covered by risk pooling prepayment schemes; and (4) almost 100% coverage of vulnerable populations with social assistance and safety net schemes. Eight proposed strategy areas were presented and discussed: (I) (2) (3) (4) (5) (6) (7) (8) increasing investment and public spending on health improving aid effectiveness for health improving efficiency by rationalizing health expenditures increasing the use of prepayment and pooling improving provider payment methods strengthening safety net mechanisms for the poor and vulnerable improving evidence and information for policy-making improving monitoring and evaluation of policy changes.
I.
INTRODUCTION
A Review of the Strategy on Health Care Financing in the Western Pacific Region was held at the WHO Regional Office for the Western Pacific in Manila, Philippines from 27 to 28 April 2009. The meeting was attended by senior government officials from the ministries of health, fmance, labour and social welfare of countries from the Western Pacific and South-East Asia Regions. l.l
Objectives
(1) To re-examine the implementation of the Strategy on Health Care Financing for 2006-2010 based on the midterm review. (2) To review the revised draft strategy on health care fmancing for 2010-2015 and propose further changes according to global evidence relevant to universal coverage, specific country needs, and perspectives of the South-East Asia Regional Office. (3) To provide recommendations for the revised regional strategy on health care financing for 2010-2015 1.2 Background
Improving population health outcomes including child mortality, maternal mortality and life expectancy is the main health policy objective across the Asia Pacific Region, and achieving sustainable universal coverage with quality health services is a major goal of health care fmancing. This region has the highest level of out-of-pocket expenditures on health care, and the greatest number of households that have been pushed deeper into poverty by health expenditures. Along with universal coverage, reforms in service delivery, public policy and leadership are also essential to promote and protect the health of communities. Because government spending on health in many of the developing countries in the region is very low, many people must rely on the private sector for their health care needs. Unfortunately, out-of-pocket health payments push low-income and vulnerable populations into poverty, especially in settings that lack effective fmancial protection and social safety net mechanisms. Reducing out-of-pocket payments is one of the three main targets of health fmancing work in the region, as outlined in the Strategy on Health Care Financing for Countries of the Western Pacific and South-East Asia Regions (2006-20 I 0). To achieve this target, the Strategy recommends increasing the use of pooled, prepaid funds to fmance improved and bettertargeted public health services. This Can be done through tax-funded systems and/or social insurance. In late 2008, the WHO Regional Office for the Western Pacific commissioned a midterm review of the implementation of the Strategy on Health Care Financing in 14 countries in the Western Pacific Region that could offer lessons in how health financing and the Strategy might be improved. Based on the recommendations put forth in the review, a new health fmancing strategy was drafted that included five strategy areas focused on achieving universal coverage by country health systems. In late March 2009, a panel of experts from all WHO regions and most of the major donor organizations reviewed the proposed strategy in light ofthe midterm review and other global evidence. This panel afforded the opportunity to integrate and coordinate the
-2-
regional strategy with global evidence and the perspectives and recommendations of other organizations. 1be draft strategy for 20J(}....2015 was revised accordingly, three strategy areas were added, and the revised draft was circulated to participants of this meeting. The agenda, timetable and list of participants are provided in Annex 1, Annex 2 and Annex 3, respectively.
2.
PROCEEDINGS
2.1
Opening ceremony
Dr Shin Y oung-Soo, WHO Regional Director for the Western Pacific, gave the opening address. He began by thanking the experts and observers for participating. He noted that health systems in the Western Pacific Region have developed in various directions. Some seem to have abandoned the ideals of "health for all", which has resulted in large populations in Asia and the Pacific, especially the poor and other vulnerable groups, facing serious barriers to health care access. He remarked that while the Region has some of the wealthiest and fastest-growing countries in the world, it also has a very high proportion of the world's most poor and disadvantaged people.
WHO will help governments address this challenge proactively. The current Strategy on Health Care Financing for Countries of the Western Pacific and South-East Asia Regions (20062010) focuses on increasing government health expenditures and reducing out-of-pocket payments. It also advocates increasing social health insurance and other prepayment and social safety net mechanisms. Unfortunately, the results have been mixed, and new impetus is needed to achieve universal coverage of affordable and quality health services. The updated regional health financing strategy will be the first demonstration of what is needed, along with strategies for the other essential building blocks of health systems, to achieve universal coverage. The opening speech of the Regional Director is attached in Annex 4. Dr Dorjsuren Bayarsaikhan, WHO Regional Adviser for Health Care Financing, introduced the objectives of the meeting. Dr Henk Bekedarn, WHO Director of Health Sector Development, also welcomed the participants and discussed the health financing strategy. 2.2 Financial crisis and actions on monitoring and mitigating possible impacts on health
Mr Armin Bauer, Senior Economist, Regional and Sustainable Development Department, Asian Development Bank, gave a presentation on the Impact of the Global Recession on the Poor and Vulnerable in Asia. He explained that this fmancial crisis is different from previous recent ones in that it is strongly affecting the "real economy" and will have the worst effects on the "near poor" in Asia, and especially in countries heavily dependent on certain kinds of exports and remittances. Social protection will be particularly important during this crisis. Dr Bayarsaikhan presented the WHO response to the economic crisis. Slides from these presentations are attached in Annex 5 and Annex 6.
-3-
2.3
Midtenn review and the health fmancing situation in Asia and the Pacific
Dr Peter Annear, WHO Temporary Adviser, discussed key issues in the continental countries and Pacific island countries covered in the midtenn review. While economic growth has been significant, government health spending has not kept pace. Extensive poverty and excessive out-of-pocket spending remain the most significant barriers to access. Social health insurance (SHI) coverage is not reflected in levels of fmancial protection, and SHI systems require capacity-building and institutional strengthening. Voluntary health insurance schemes have suffered from slow uptake, limited risk pools and high drop-out rates. Targeted subsidies are most effective in providing access for the poor. In contrast to Asian countries, government funding is high in the Pacific and out-of-pocket expenditure is not a major problem. Many important specific health needs are not being met, but small populations present issues of economy of scale for most interventions, including SHI. AlJocative efficiency needs much more attention, shifting to secondary prevention from tertiary treatment.
Dr Steve Fabricant, WHO Consultant, summarized the fmdings of the midtenn review in implementing the current strategy in the Western Pacific Region. Some progress has been made in increasing government health spending in the Region, but total health expenditures are still quite low in many countries. Out-of-pocket spending has been reduced by the introduction of SHI and safety net mechanisms, but remains high in most countries. Effective coverage of SHI is low. Provider payment methods encourage out-of-pocket spending. Resource allocation is still in favour of hospitals. Financial management and efficiency issues need to be addressed. Dr Alaka Singh of Health Systems Financing, Department of Health Systems Development, WHO South-East Asia Regional Office, gave an update on health financing in South-East Asia. In addition to high out-of-pocket expenditure due to user fees, other main issues are low government spending on health, a large and poorly regulated private sector, and inefficient use of resources. SHI is in its infancy because of the small fonnal employment sector. Functional strategies for progressing in these areas need to be elaborated. Links to the efficient use of pharmaceuticals and other health system issues need to be clarified. Slides from these presentations are provided in Annex 7. 2.4 Health fmancing strategy for 2010--2015
Dr Bayarsaikhan gave a presentation on the background to the new strategy and the operational defmition of universal coverage. Global evidence shows that catastrophic payments and impoverishment are high where out-of-pocket expenditure is high and government health spending is low. The new strategy fits within the WHO framework of health system strengthening and follows a logical path towards universal coverage. The revised strategy targets or progress indicators are: (I)
out-of-pocket spending should not exceed 30%-40%;
(2) total health spending should be at least 4%-5% ofGDP, with 500/ .....70% of public fmancing; (3) over 90% of the popUlation is covered by risk pooling prepayment schemes; and
(4) almost 100% coverage ofvuInerable popUlations with social assistance and safety net schemes. Slides from this presentation are provided in Annex 8.
-4-
2.5
Proposed strategy areas and actions
Dr Bayarsaikhan and Dr Fabricant presented the proposed eight strategy areas and relevant actions: (1) (2) (3) (4) (5)
(6) (7) (8)
increasing investment and public spending on health; improving aid effectiveness for health; improving efficiency by rationalizing health expenditures; increasing the use of prepayment and pooling; improving provider payment methods; strengthening safety net mechanisms for the poor and vulnerable; improving evidence and information for policy-making; and improving monitoring and evaluation of policy changes.
A lot of relevant and useful feedback was provided by the participants after each strategy area was presented. Slides from this presentation are provided in Annex 9. 2.6 Summary discussion and recommendations
Dr Peter Annear presented a review of the participants' recommendations and comments (Annex 10).
A revised draft of the health fmancing strategy will be prepared for final review.
ANNEX I REVIEW OF THE STRATEGY ON HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION
Manila, Philippines 27-28 April 2009
AGENDA
1. 2. 3.
Opening session Financial crisis and health Midterm review
4. 5. 6.
Health care financing strategy for 2010-2015 Summary discussion and recommendations Closure session
Al"lNEX 2
REVIEW OF THE STRATEGY ON HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION Manila, Philippines 27-28 April 2009
TIMETABLE TIME 09:00-09:30 I I .
27 APRlL (Mon) Registration I.
TIME 08:30-10:30 4.
28 APRIL (Tue) Health care financing strategy for 2010-2015 (Dr 0 Bayarsaikhan; Dr S Fabricant)
09:30-10:00
Opening session
4.1 4.2 4.3
Presentation and discussion: Strategy Area I
!
• • • • 2. 10:00-10:30
Speech of the Regional Director
Presentation and discussion: Strategy Area 2 Presentation and discussion: Strategy Area 3
Introduction of participants Election of Chairperson and Rapporteur Introduction of objectives (Dr 0 Bayarsaikhan, WHO, Western Pacific Region) Financial crisis and health Possible impacts of the current economic and financial crisis on health from Asian country perspectives (Me A Bauer, ADB)
•
10:30-11:00 11;00-12:00
• •
GROUP PHOTO/COFFEE BREAK WHO response to the economic crisis (Dr H Bekedam; Dr D Bayarsaikhan, WHO, Western Pacific Region) Discussion on financial crisis and actions on monitoring and mitigating possible impacts on health LUNCH BREAK
10:30-11:00 11:00-12:00 4.4 4.5 12:00-13:00 13:00-15:00 4.6
COFFEE BREAK Presentation and discussion: Strategy Area 4
Presentation and discussion: Strategy Area 5 I
12:00-13:00 13:00-15:00 3.
LUNCH BREAK Presentation and discussion: Strategy Area 6 Presentation and discussion: Strategy Area 7 Presentation and discussion: Strategy Area 8
• • •
Midterm review Major findings ofmidtenn review (Dr P Annear, WHO Temporary Adviser Progresses in implementing the Regional strategy for 2006-2010 (Dr S Fabricaut, STC) Health financing update in South East Asia (Dr A Singb, WHO, SouthEast Asia Region)
4.7
4.8
15:00-15:30 15:30-17:30 17:30
COFFEE BREAK
15:00-15:30 15:30-17:00 17:00-17:15 -----
COFFEE BREAK 5. 6. --
•
Discussions on midterm review findings, progresses and practical application of results-based financing
Summary di'scussion and recommendations Closing session -----
Informal reception hosted by the Regional Director ---
ANNEX 3
REVIEW OF THE STRATEGY ON HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION Manila, Philippines 27-28 April 2009
LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISER, REPRESENTATIVES/OBSERVERS AND SECRETARIAT
1. PARTICIPANTS
WESTERN PACIFIC REGION CAMBODIA Dr Kanha SOK, Deputy Director, Department of Planning and Health Information Ministry of Health, No. 151-153 Avenue Kampuchea Krom, Phnom Penh lei no. 855-23881408; Email: kanha@on1ine.com.kh Ms Thavary KROUT, Deputy Director, Budget and Finance Department Ministry of Health, No. 151-153 Avenue Kampuchea Krom, Phnom Penh Tel no. 855-23881408; Email: thavary_kh@yahoo.com Ms Phath PHUM Deputy Chief, Bureau of Health Economics and Financing, Department of Planning and Health Information, Ministry of Health, No. 151-153 Avenue Kampuchea Krom Phnom Penh: Tel no. 855-23881408; Email: thavary_kh@yahoo.com CHINA Dr Guang SHI, Director, 2nd Division of Health Policy Research, Department of Health Policy and Regulations, Ministry of Health, No. I Xi Zhi Menwai Nan Lu, Beijing 100044: Tel no. 861068782692; Fax no. 8610-68282883; Email shiguang@moh.gov.cn
Mr Qinghui YAN, Division Chief, Resident Medical Insurance Division, Hepingli Zhongjie 12 Medical Insurance Department, Ministry ofHurnan Resource and Social Security Beijing 100716: Tel no. 861084207422; Fax no. 8610-84207424; Email yanqinghui@mohrss.gov.cn Dr Yu JIANG, Director, Department of Social Security, II Sanlihe Xicheng District, Ministry of Finance, Beijing 100820: Tel no. 8610 68551226; Fax no. 8610-68511052; Email jiangyu@mof.go.cn FIJI Ms Mereia SAUROUTU, Ministry of Health, Principal Accounts Officer, Box 2223, Government Building, Suva: Tel no. 679-3306-177; Email: MsauroutuOOI@health.gov.fj
Annex 3
LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Khambung HEUANGVONGSY, Deputy Minister, chairman of the Central BCH Management Committee, Ministry of Health, Vientiane; Tel no. 856-21253017; phcepcab@laotel.com Dr Somphou DOUANGSAVANH, M.P. Vice-Chairman of the Socio-Cultural Affain; Committee Vice Chairman ofLAPPD, Lao National Assembly, That Luang Square, P.O. Box 662, Vientiane Tel no. 85621911524 Mr Khampheth MANIVONG, Acting Director-General, Department of Planning and Finance Vice Chairman of the Central CBHI Management Committee, Ministry of Health, Vientiane Tel no. 85621 223110; Email khamphetrn@yahoo.com Ms Bounthay LUEANGVILAY, Deputy Director General, Budget Department, Ministry of Finance 23 Singha Road, Nogbone Village, Saysetha District, Vientiane, Tel no. 85621 452313 185620 0801702 Dr Soulivanh PHOLSENA, Senior Health Planner, Department of Planning & Finance Ministry of Health, Simuang Road, Vientiane, Tel no. 85620 7812313; Fax no. 85621 217850; Email dr.pholsena@gmail. Mr Chaikham CHAMPA OUTHOUM, Prime Minister's Office, Ban Viengcharoen, Vientiane Tel no. 85620 2205335; Email ChampaOuthoum@yahoo.com MALAYSIA Dr CHUA Hong Teck, Director of Social Services, Economic Planning Unit, Prime Minister's Department, Block B6, Level 3, Federal Government Administration Centre, 62502 Putrajava Tel no. 603-88883680; Fax no. 603-88883689; Email chuahongteck@epu.gov.my Dr Abdul Rahim ABDULLAH, Deputy Director, Planning and Development Division, Ministry of Health, Level 6, Block E6, Federal Government Administration Office, 62590 Putrajaya Tel no. 03-88832128, Email rahima@moh.gov.my MONGOLIA Mr Tseveendorj GURDAGV A, Economist, Ministry of Finance, Government Building-2, United Nations Street 5/1, U1aanbaatar 210646,; Tel no. 976 II 264328; Email !se_dorj2000@yahoo.com Ms U1zii-Orshikb KHALTAR, Officer in Charge, Health Financing and Foreign Loan and Aid Policy, Strategic Planning Department, Ministry of Health, Building 39B-35, Khoroo 18, Bayanzurkb District, Ulaanbaatar: Tel no. 976688091221; Email UlziU972@yahoo.com Mr Otgonkhundaga SHAR, Deputy Director, Policy Implementation Coordinating Department, Ministry of Social Welfare and Labour, United Nations Street-5, Ulaanbaatar 210646 Tel no. 96661442; Email otgonhundaga@yahoo.com PAPUA NEW GUINEA Mr Navy MULOU, Health Economist, Policy Planning Branch, Department of Health P.O. Box 807, Waigani. N.C.D;, Tel no. 6753013638; Email navy_mulou@health.gov.pg
Annex 3 PHILIPPINES Dr Ma Virginia Guzman ALA, Director, Health Policy Development and Planning Bureau Department of Health, Building 3, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila. 103 Tel no. 632-7438301; Fax no. 632-7116736; Email marvie_ala@yahoo.com
Dr Leizel LAGRADA, Officer-in-Charge, Health Policy Division, Health Policy Development and Planning Bureau, Department of Health, 2F Building 3, San Lazaro Compound, Rizal Avenue Sta. Cruz, Manila 1003: Tel no. 632-7814362; Fax no. 632-7814362; Email leizel.lagrada@gmail.com Dr Madeleine DE ROSAS-VALERA, Senior Vice President, Health Financing Policy Service Sector, Philippine Health Insurance Corporation, Room 1912 Citystate Center, Shaw Boulevard, Pasig City Tel no. 6326383607; Fax no. 632 6871151; Email madz_valera@yahoo.com Mr Ruben BASA, Group Vice President, Philippine Health Insurance Corporation Citystate Center, Shaw Boulevard, Pasig City: Tel no. 6326376260; Fax no. 6326376237 Email johnbasas@gmail.com
SAMOA Ms Nafanua NGAU CHUN, Senior Accounting Officer, Ministry of Health, Private Mail Bag, Apia Tel no. 685-68100/68136; Fax no. 685-28596; Email nafanuan@health.gov.ws TONGA Mr Tu'akoi 'AUlO, Principal Health Administrator, P.O. Box 59, Nuku'alofa Tel no. 676-23200; Fax no. 676-24291; Email tahio@health.gov.to
VIETNAM Ms Nguyen Thi QUYNH PHUONG Expert - Department of Public Expenditure Administration, Ministry of Finance, No. 28 Tranhungdao Street, Ha Noi: Tel no. 8422202828 14027; Email quynhphuong2112@yahoo.com
SOUTH EAST ASIA REGION SRI LANKA Dr H.S.R. PERERA DE SILVA, Director Policy Analysis & Development, Ministry of Healthcare & Nutrition, Colombo, Sri Lanka; Email susiepds@gmail.com THAILAND Dr Phusit PRAKONGSAI, International Health Policy Program (IHPP) ,Ministry of Public Health Tivanon Road, Nonthabnri 11000, Thailand; Email phusit@ihpp.thaigov.net Ms Kanjana TISAYATICOM, International Health Policy Program (IHPP), Ministry ofpublic Health Tivanon Road, Nonthabnri 11000, Thailand; Email kanjana@ihpp.thaigov.net
Annex 3 2. CONSULTANT
Dr Stephen FABRICANT, Health Policy, Economics and Management, Hantagawa 4-12-38, Naha City Okinawa 902-0071, Japan; Tel. no. 819-88550530; Email sfab43@hotmail.com
3. TEMPORARY ADVISER
Dr Peter ANNEAR, 25E2 Street 178, Phnom Penh, Cambodia; Tel. no. 855-12514979 Email lowannear@bigpond.com
4. REPRESENTATIVES AND OBSERVERS
ASIAN DEVELOPMENT BANK (ADB) Mr Jacques JEUGMANS, Practice Leader (Health), Poverty Reduction, Gender and Social Development Division, Regional and Sustainable Development Department, 6 ADB Avenue, Mandaluyong City._Philippines; Tel no. 632 6326392; Fax no. 632 6362409; Email jjeugsman@.db.org Mr Armin BAUER, Senior Economist, Regional and Sustainable Development Department (RSDD) Asian Development Bank, 6 ADB Avenue, MandaJuyong City, 550; Tel No. 6326325550; Email abauer@adb.org
5. SECRETARIAT
WHO Regional Office for the Western Pacific Dr Dong II AHN, The WHO Representative in Lao People's Democratic Republic 125 Saphanthong Rd., Ban Saphanthongtai, Sisattanak District, P.O. Box 343 Vientiane, Lao People's Democratic Republic Tel. no. 85621353902; Fax no. 85621353905; Email almd@lao.wpro.who.int
Dr Henk BEKEDAM, Director, Health Sector Development. WHO Western Pacific Regional Office U.N. Avenue, 1000 Manila,_Philippines, Tel. no. 632-5289802; Fax no. 632-5211036 Email bekedamh@wpro.who.int Dr DOIjsuren BAYARSAlKHAN (Responsible Officer), Regional Adviser in Health Care Financing Division of Health Sector Development, WHO Western Pacific Regional Office U.N. Avenue, 1000 Manila. Philippines; Tel. no. 632-5289808; Fax no. 632-5211036 Email bayarsaikhand@wpro.who.int Ms Anjana BHUSHAN, Technical Officer - Health and Development, Division of Health Sector Development, WHO Western Pacific Regional Office, U.N. Avenue, 1000 Manila, Philippines Tel. no. 632-5289814; Fax no. 632-5211036; Email bhushana@wpro.who.int Ms Lucille NlEVERA, Programme Officer, Health Care Financing, The WHO Office in the Philippines National Tuberculosis Centre Building, Second Floor, Bldg. 9, Department of Health Sta. Cruz, Manila, Philippines; Tel no. 632-5289769; Fax no. 632-3388605; Email nieveral@phl.wpro.who.int
Annex 3
WHO Regional Office for South East Asia Dr Alaka SINGH, Health Systems Financing, Department of Health Systems Development WHO Regional Office for the South East Asia, World Health House, Indraprastha Estate Mahatma Gaudhi Marg, New Delhi 110 002, India Tel. no. 9111-23309327 Fax no. 9111-23370197 Email singha@searo.who.int
ANNEX 4 OPENING SPEECH BY DR SHlN YOUNG-SOO WHO REGIONAL DIRECTOR FOR THE WESTERN PACIFIC AT THE REVIEW OF THE STRATEGY ON HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION 27- 28 APRIL 2009 MANILA LADIES AND GENTLEMEN GOOD MORNING! I would like to extend my sincere appreciation to all of you for participating in this important meeting. The national government officials and health financing experts from two WHO regions gathered here to discuss the findings of the mid-term review of health care financing and a new regional strategy for Asia and the Pacific for the next six years. This task is daunting. Health systems in the Western Pacific Region have developed in various directions, and some seem to have abandoned the ideals of health for all. We know that large populations in the Asia and the Pacific, especially the poor and other vulnerable groups, face serious barriers to health care access.
Now with the global fmancial crisis threatening the economic security of millions more people, it is even more important to review and improve current health care financing policies. We must ensure that everyone has access to quality health services, without facing crippling financial burdens. But these also are hopeful times. We see renewed commitment by Member States to the basic principles of primary health care, with equity and universal access to quality health care as the guiding principles. WHO believes that this commitment is the best way to extend to those most in need the health gains that others in the Region have enjoyed. Last September, the Member States in the Western Pacific Region adopted a resolution that called for a regional strategy for strengthening health systems based on the values and principles of primary health care, and highlighted the vision of universal access to quality health services for all. Our updated regional health financing strategy will be the first demonstration of our commitment to put in place what is needed, along with other essential building blocks of the health system, to achieve universal coverage. The challenges facing WHO's South-East Asia and Western Pacific regions are enormous. We have more than half of the world's population with some of the wealthiest and fastest-growing countries in the world. But we also have a high proportion of the poorest and most disadvantaged people. Millions were lifted from dire poverty by the economic growth that preceded the current. But the share of health care costs paid directly out-of-pocket by people in the Asia Pacific region is the highest in the world. This has pushed large numbers of households back into poverty, and the economic downturn will make many more people vulnerable to these effects if they do not have adequate protection. WHO and other development partners recoguize that this is a problem governments can and should address proactively. The current Strategy on Health Care Financing for Countries of the Western Pacific and South-East Asia Regions clearly focuses on increasing government health expenditures and reducing out-of-pocket payments. It also advocates increasing social health insurance and other mechanisms to do this. Unfortunately, the results at best have been mixed. New impetus is needed to achieve universal coverage of affordable and quality health services.
Annex 4 The economic crisis also makes it even more important to reinforce the link between health and social and economic development, and to resist cutbacks in health funding. Nations need a healthy population to prosper. More than that, ensuring access to health care will mean that families will not need to set aside savings to pay future hospital bills. The money they save can be then be spent on other family needs. It is exciting to see the wide range and depth of expertise among participants and experts attending this meeting. Your collective expertise and experiences should help build the case for a stronger political commitment for financing equitable health systems. We are looking forward to your active participation and contribution in improving the health care financing strategy for the two regions - South-East Asia and Western Pacific. I have no doubt that your expertise and experience will ensure the success of this meeting. I look forward to reviewing your conclusions and recommendations.
Thank you and have a pleasant stay in Manila.
ANNEX 5
Impact of the Global Recession on the Poor and Vulnerable in Asia
This Is about encouraging dlscus.lons and exchanging Ideas not about health (nevertheless Interesting for you) briefing on September Conference with ASEAN
Dr Armin Bauer Sanlor Economist
Reglonal.nll Sustalnab.. Davelopment Oepartmant
AsI.n Development Bank
How is the global crisis spreading in Asia (economic realltl •• and Impact channels)? 2. 1998 and 2009 • what Is different? 3. Impact on People; what are poverty and social impacts •. Discussing potential response 5. What can the health experts do? What can ADS do? 1.
1. How Is the global crisis spreading to Asia Some Infonnatlon on the economic side of the crisis
How is the global crisis spreading to Asia: Is lite enI of high growth coming to an end?
--=__ ~
_ _ _ _ _ : _ _ _ _ ... ~ ........ _ _ _ iooA51 • • G:I
_ . . ._..........-_.,a.. "' .... .,...wof_ ___ :t::-.:.~=~
. . <i( _ _ _ _ _ .... _
. .IEot, ...
~ ... _~ _ _
==:::...-....... - ........ ,._ .....,--......- -... """""-----' ........ -.......... ---.. - .._IIoOOP:J ... f.. _ ? ) ... _AD8~l...t'II.for .......... _ :.:.1oo.;:..~
""'r_....-_1WQ'
15OC.... JIHIl)IO_(-
__ .. _-_ .. P t t I I - + - I t - - ..
.. ADra _ _ ...,., _ _ k(Ap<2OOII) -~-
2. Impact channels: from monay to people Overview In 2001: REBAL.AHCING ECONOMIES T~d.
hnpact channels: from money to people 199715 very different from 2008: The economics are different. The social policies also need to be different. So are poverty Interventions.
_._u. _, . .
FOlia failing Acceu 10 flnanc:e
J,", labor mQrkets
Social protection
--(
Social budgeb
Social fabric, poIitirr;:,.l . .bliy
......
)
Annex 5
3.
From money to people - Labor markets impacts
From money to people - remltblnces R• ....m..- n-. _ ~ to __ ~ »D5 bIlIon InlllOl llflrM ti.... tt.. _lid o~; tt.t. Is • .n-p dIcIirw since mid 2001 .e.a.- forTAIINtM aMwthlt ........ tho ~tIow.GUId ......... powrty ~ fnonI 53'1(1'1''''to 8O'IIoIZ:I"I. .nddMJ-n~IIIId~ PaItIcuWIy ..r.c..d _ c.MnI .... __ South AsNo
• Rising unemployment among the urban educated
youth • Informallzatlon of the labor market; value chains; labor standards • Gander dimensions
E>totri""'_ PHI,SRI _ _ ..... r ....... N5l'-
_....
• Is the effect on the labor market really do serious?
""" , __ _ -"""_'~.i<""",.....-.",._.,..,.......=-,,,,_
-~_"'pf.M_"._l'CP%~ W.. _ _ .... _ 1
. _ ..... _ , " ... _"1oy1
-""
..-'----~~
.;<
-
-b_
~"' .F........... , . . . .
--10 _ _ _ _ _
-
,,""'~_1
From money to peopleSocial servtc;es: Social sector s~ndlng and municipal development
From money to people - weakening social fabric ~
• In many countrie5 fiscal preuure will ,esult in reduced services to the poor Different to the financial erial. 1991, go_nme"t policies and donors do not yet discuss the need to protact social spending -jo
• Back-nUgration to rural arua PR China story • In the rural _ _
daM not really happen; the
:~~r:ral~uncgJ-o!; ~~
..:nJ?ron says
20% of budget
-+ :~::~ :~~-:.)~ ... tdy caus.d rising malnutritloo (<W -jo h...,Jly affected Is the health budgK increase in infant and moltler mortality (henci tn. ""d-for .odel hHltlllnsurance' -+ sloWdown In MOO achlavl1llant -+ _ 111M a majOf problem for etlvlronlMl'ltai MOG (11 oilS local
• In the cities: more sJwns ~ nHd for housing for the vulnerable poor - incl'easing dJuatlatacrtlon, violence Gender: are women the first to b. leld off? can they cope better btlcause they are more flexible in increasingly informal labor metkats?
gOV1lmmetlbi ..re most hit, " ....eD. Pleuge. do not provide additional funding tot deoennRzed govwnmen1s; slum
~e:;~==:~ ~~c::,~ bathe most
From money 10 people - gender
From money to people - will poverty Incr.".e?
•
...... -
- Huge gender .cIulty gaP' bmwHn South Asia and East Asia - , ... cnsis ~ women 1tIrough
·
CUrTent rec:esslon: - Woman forma major PIIrt of 80ma labor mal1tats (textile vs. machln. bullcllngl MIgrants and relftlttanc., • some woman are prot.ctadkt.'f haalth work_", in USA), others heavny affected (ma , • Hot '0 much impact on tn01tIer heath • ImpUcation' on famUy bl.ldgets - Addlt/onal,trus and vIo"nce both urban and rural 1"-'& _""",COl i/I."4'C>~ tndUltnn (by 2CQIi)
f:---...= .. - ...
f•. : : - ,'.
! _.
•
I M
..... "'...
MlllllydIoil
~-
-~
-
.. .
g........ w ~~ ~b
......
""f.......t""", belt'lll
.Itctroni""
" >"'"
.... ""
II -
--.. ': : -- -- . .~-
-
_ft_._1.1IIe"".. -.......y_ .. at10, .. ~1:11 _ _ h.... " ' _ ..... _ ....... w _ _
~ .~ ,:
.- . ,-
----_.- ~
.
. :1 -I "i
- ....::.....,=...~
- -- --
-
-
Annex 5
POVerty and social impacts -the MOGa wtU the MOGs in the region be affected? YES - whila economic growth do. not automatically triclde down
From money to peop&e Will tha MDGIii in the region be affectect1Probably yes. if the crisis Is not seen &IIi an opportunity to address IIOdaI and envirorwental poverty
to social achievements No trk:~ dawn;
8001.. I""" ............... do not ~Iy ..I. . " d .... ctlyt .. g..........nthan I n _ povuty. (IND-SRI tofofy) ElIllltJcttiu: A 3% reduction In GOP .... uItIIln 2,140 mor. mlltem,' dNth (Pfi 1OG,aaa Ilva blrt ....), 541,000 mo .. chlld..n unn. S dylnll (1M' 1,000 nv. blltheo), 1..4 million ........ chlldran bellll undoorw.lght, ,nd 7.8 mlWon more .,-.. pIe ",lnll hungry. H<>w-, .uen numblonl IIMd to IMo IntIorpNtld wry canofully.
-_ ...... :::
o.n.v """"', ..... r - _
..n.................... and..,.,..,. funding, «elMs not •.,....,.. . . ,....., _ ~ for I\IdIng auchAfVice priv.aty
....
to
&IIIIbk...n- provIdBL . . . . ~ In INGtI
(COf"I~cMll.traIISfws, ~"""_)
O!I poor.nd . . ......,.... ......
---- _----~
"'.-. ---, -'. --. _. .... ..-- -_ _M
_ -- _MOO ..
_ .. _ ......--=.:0.-
....
...._.
Poverty and social impacts
Poverty and social impacts Health (2)
~
'Cnt,bad MOO tr.cIt ...,ord on ........, '1IPK1al1y mother
ADS haa _rse health Indicators III... 5S-Nrk:o High oul of poc:Ut expondltuR, I....., 11...........111 oxpandftl.ns ~""'''''id DIth .. child ",-.Illy ..tr.ot. ,ntlra ...... AIoI..pac/flc ond In 2003 h :rJl::ti~i= ':" ~=n1'o~ 1::'1II1~~lovor 2 mI on), Chino (over • Vlrd GI mlrtamol dHth:Iln "ilion In 2003 toall pI,ce in Indio ond
...
tJ.
'::t:t.
-~-
::.Jr.......
. - ..-.--
P,kOotoIn ,10_
I~
""P-I of tho ...... 18 ..., hHIth ........ (S) ond .... on IMaIIh programs ...... to ...... _dWogUl ......... ~
of ttw """-" 91 .....1r--.ioR:
-
• .....-:c:ubin ...... _UIMY _ Po........, from prMD to publio ptlJIIIdoInI
-+ d _ ........._ -;
......... 1
Thillllltt.
but O!I . . \WIndow .......... , - ..... the.....,.a.. ... ___ ......
-.--
~
.....
ta " ' " ,~ _
............ ___ .......... ~
~
Poverty and social impacts - the MOO. The urban story CIoN 'Inb w..-n u~ Md.~ng hHIIto: T1Io old s'loty. T1Io _ ~
4.
So what shall be done? The 3 myths 1. 2.
-*.....,.taIb abaut"'r but IICItu.ny not" much I~ good ~1n_' ..... ln . . . . .1cin on"''''''. pnlb-Itom, In tho IlulM
._rtoon..
China cannot save the wond In Asia, it is not about flnance, not so much about the regional dimension, and not only about the economy: trade driven growth trickledown spreading Inequality Is not an option any mora; the need for "rebalancing" Tne social dimension snail not be neglected; growth does not take care of it: no is the time for new social opportunities
-t Tho
...,;...: oon..lClon _nd _ _ , tnffIc ... d """Iants, cIInwho ch.nge 3110'"' I hauslng J .. um upgndlng 1:1 MgIot<:ted
~on
_ etr.. _lid viall".,.: ~1tIq. vii_a-. _ "01111.... inoII:;Ibillty _nd wi_in o.c.ntnllullion _ _ III hltp1
MI"onel oday on tM ~1Iy UrtMn low Inc_ mOIHl to .tu_ -* hou-Ing
•
• L:I"" I*f IArJO
01 _ _ pocbgIa II on 1M aI\ouIdIno of Ioc:II 9 O n _ oenInII,...nding for 1 f I f r _ ........ fIMnGIng for ...................
3.
Annex 5
So whet shan be done? Are the stim .... us packages doing the right thing? The first generation ..• and
--
-. -. ........ ~, '
~"':-
. . . . _-"1 --- .-_._-----...,_ ..... ,_ _--,,_ __ -- ... -_ -----.._"""'.. ""--'--, =:::.:.":..(G>~"'
So what shall be done? Are the stimulus packages doing the right thing? •.. and the second generatIOn
__ •
"-
..
.,....,.,,~~'!I;<'<
__.•
~,.!>kr'""""'"
....- ....,
......
~.,,_._,
, "
~--
_ . . ."""" "'-!""..... ......., ~:-~.
-'"'...-~
.....
'.-.;:,_
..
,., ••• ;"
>
So what shall be done?
5. What can ADS and WHO do? Principles More money ~
StrategiC auggestions
,,•
AaIro .. doing awprbIngIy . . . Furh. lftOftItoring. Mel ..tt.ngIhen1n. of .,........ - - . : I (CbWI ... 1n1lMlve,
Yes, tIul for What?
_.J
• •
More knowledge to do the rigflt thln8s How? Quick and sysam.c WIth whom? Partnership Forwhom1 - The big guys dr_thl attlntion: PRC, IHD, VIE - What o.bout the neglected one.7: PAC, CAM. BAN, T.u
El>Dflomy.
•
•
RebIII ...... ff'OfII_ ..... dl't¥en to d~ (*nd ~I grvwtfI Infr..t ... ctun: yes but ttM rigttt _ : urtIan aIUIft ttpgI1IdlnO. thot rai_ Jot.: Iha rainbow appnNIGh (II""" Nd, biw): ....., WId . . . IItchnoiogy 8oc1.1 prolIIIetlon for~ g..-th
'ftw,1JOCi.t.ldII F.oIII 1M ~'Y poOl" ($1-Z5) tl> the ""1.......'- poM (U) SoeI.t pR>llOCtion implication., from oah to lnaurano;e ..rom the Pl"0f 10 tha VlI ....,... poor ... Impl/t:IIIIo,. for .oc:illl pnotactIon
-,-
rr.""',
From "'..I __ ........ m to alum ""~nI? From ....1c lcIlabor marbt ..-.m •........,.; IiGhoIanohlpll; foo;:. . on the
Other le$$Ons Be (:4JI'efu11n election yurs, ..peclaUy VIfth programmatic lendin8 Do not mix the prob-..ns: PAl( Bu$lnes:l as usual I, periI.ps over, bill n Is nOi so baclalther __ We need to knuw more
Prot.ct .... ,.,....., the ___ *-'cIN ('-fill InMnnCII)
What can ADS do? Suppoft structural rebalancJng
WhM shall WHO do?
ADB • Operations - More money: 11.5+3.6 - Special fund (4 blo for 2 years) (health finance) • Knowledge and strategy - Presidential Paper at Annual Meeting - Annual meeting seminar on MDGs, - Conference with ASEAN on aoclallmpact of the global economic slowdown In Sept 09 (Vietnam) 2} Our joint study cooperation for September 1) ?
Annex 5
What can ADB do1 Support structunll rebalancing The Sept 09 conference
What can ADS do? Support structural rebalancing The Sept 09 conference
a 0111 ... kol .. n ...... _ _ p _ .....
Thelrnpact m u. Global R&ceuIan on pov.rty and Soc>I.1 D.nlopment In Mia
•
3td Chin.,,8EAN Forum
fI6d"_.
ANNEX 6
Declines In GOP 2008-2009
WHO Response to the Economic Crisis Dr H. Bekedam Dr 0 Bayarsaikhan
IO.n;
• ZOO8 .2008
.,....
Big Picture - the Impact on Health
Learning from past: domestic health spending When countries are in recession:
Inputs
Outputs
Outcomes
1.
Private expenditure on heatth has always fallen - househokt
Incomes fall (unmet needs, self-medication with cheap opt~n5)
2.
Government expenditure on health has often fallen, partly
I:::~I
because government revenues fall.
IH"~h
3. 4.
capital expenditures (infrastructure development and supply of equipment) are often delayed. Where there is a devaluation of the local currency, problems
for Imported goods - e.g. medicines. Thev betome more
e)(penslve in ioeal currency.
Learning from past: external aid for health OfIIoioI~I_"I~fQr-,_"",,,,,,,,,,
[In _ _
I1"'~
__
Learning from past: service utilisation and health status Health service utilisation and health status could be adverselv effected: Increasinl burden on government services: more demand and '-55 resources. he5Sure to upand ",er fea: OOP Increase. Rectuced availability of services: hilha, cost of medicin••• nd teehnolosies. l\edueed household Incomb; ch'IlIU In spendln, pattern (self m.dlc.tlon), stress, IIf ...JtyIe .nd behaviour dI.",e. Intnased unemploym...t: pnoerty 1M ""lMrIbilily. Nq.ti"H Impects on health: 1M", MMR and .dutt m.&' moft;lllty.
Annex 6
Future developments TM view on th" hea/ttl IlIIpadI Is not deaf .,et: WfWdI coumrles1 How
Supporting environment Fiscal position of some developing countries stili can support employment and $pend an social safety net pragrammes. Many governments are aware about the viral role of health far socioeconomk development (CMH, SOH)
levele? H_long? It Is an opportuIrity f'IH policy dla"le and build more ~uitaw. and efhctNe hHItt. systems. We ndd to H p'apared:
.<"0.".
1. ProvIde evidence buR arpments for pofity dI.lopes, polky tN. and
2. Improve health info~ wtth real time dab to II\OIUtOr the bufth impliCb .,.d acdons to n111tiph the neptMi! hulUl consequ.nces.
WHO firmly supports untversal coverage as way to improve health. It Is I core component of PHC. Member States support HSS framewark to Improve health outcomes.
3. AmsI: COUntries In ptGtKti", health sp.ndillfl and stre,..thMlna sod.. hHtttI prot.dkln. e.l. by watdllnl tvr spa.....I"'.
lie...,.
WHO global response High level consultation on the financial crisis and global
Regional actions Health in times of global economic crisis: Implications for the WHO European Region. Meeting in Oslo, 1·2 April 2009 Mtp;Jlwww eyre who.who IntlDpcymeOWSMIO"9 De Erial• •mptlF pst(
health, Jan 2009. Framework for action: 1. Leadership 2. Monitoring and analysis 3. Pro-poor and pro-publlc health spending
4. Policies for health sector 5. New ways of doing business www·.... bg!nlhn,dlt!1l!W.i1.... nlelm...Ii...!I'908 WHO s'**"-" tOT u.rgar. Chlln. 00) cA!t p ....1t
WHO Region for the Western Pacific: WPRO Regional Director's address, Feb 2009 Health financing expert meeting, Mar 2009 9&d' Consultation of WRICLO, Apr 2009 Review of health financing strategy. Apr 2009 Regional Committee meeting, Sep 2009
not ....".
In
www.wlKl .• ntl..... dl.c.ntNlnew ..... u.tamental2GGaA.in.ncl •• _crt.Ia_200ll0401 •• nlprint.htmI
Further actions ADS and WHO JohU study In four countries Evidence based advocacy package Communication strategy
Effective partnership
Monitoring and Impact assenment
ANNEX 7
Regional survey of health financing
Survey countries o ASIA 6: Cambodia, China, Lao PDR, Mongolia, Philippines, Viet Nam
Dr Peter Annear WHO Consultant Globalism Research Centre RMJT University, Melbourne
o PACIFIC 8: Cook Islands, Federated States of Micronesia, Fiji, Papua New Guinea, Samoa, Tonga, Tuvalu, Vanuatu
Situation o Diverse region in terms of population, economies, health financing
Key issues ~~i:Uh~~~ to nivtlrSll M'U
o 5/6 Asia are countries in transition o Period of rapid economic growth until 2009
.."
~!nains very low by world ~~d9et is a high % THE; andards
rnment spending
HE Is low; Government
ot adequate fur advanced echnologil5
but
a~ss
to
~.ntlal health
Igll OOP Spending remains ~! sP\!Indlng has little main barrier to access mpact but ctl-payments are n issue In some countries
o Pacific region: (except PNG)
ustainioble finandng
small iSland states
runds for $Ome hlNlth programs
Igh reliance on donor
jfo; SOfTIe health programs
I9h reliance on donor funds
Key issues
Asian region SEA.,,, PIC~
,
Key 10;' II'
o Summary of main findings
mpact of catast.ropPlIC aln need Is to protect the ealthcare payments ~i and provide access to
ot significant far basic ervlc;:es - those who cannot <IV get care
Ices
lfY"dency In resource UC seMmes suffer from
".
loeffh:lency and limited
",th
sector technical and ilocltlVe emclency tan be ~ved (current focus 011 Public
pharmaceutical sector)
Annex 7
Main findings D While economic growth has been significant government health spending hali not kept pace o
the most Significant barriers to access
Extensive poverty and excessive OOP spending remain
[] SHI population coverage Is not reflected In levels of financial protection o o
SHI sptems requite capacity building and Institutional strengthen'ng
3
! :
slow uptake, limited risk pools and high drop-out rates
Voluntary health Insurance schemes have suffered from
D Targete:.cl subtlldles are most effective In providing access for the poor
Composition of THE
o Out-of-pocket spending is still the main source of financing o Government financing is not adequate o Social health insurance has not yet had a major impact on reducing OOP
-r
I -- - -......-~..lI
-,I' ~-==------t--i n..........,.-----
----
I
=
!
M'~"'-
o Mongolia performs the best on financial protection
--I -,.......-...-
I J ---,::i
---,M
I = '"'.
Depth of universal coverage
LIC - coverage
o SHI share of THE does not match population coverage o Must discount for administrative costs
o Cambodia, Laos and Viet Nam o The most immediate need is coverage o Main issues: • Increased government spending • Implementation of SHI • Scaling up of subsidy and SHP mechanisms
o An accurate measure of financial protection is needed
• Changing disease patterns
Annex 7
LMIC - efficiency Cl China, Mongolia and the Philippines
Pacific islands
o
o Summary of main findings
The most immediate needs are alloeative and technical efficiency of UC schemes
Cl Main Issues, • Extension of tbe SHI beneFit package • Proper Integration at financing schemes • Integration of provider agencies • • Appropriate decentralization Hospftal reform
•
Reform of HIS (including NHA)
OOP payments are not a barrier
Fiji: Pharmaceutical expenditure
fiji
Pog\la Ne'.v Gui"(l~
S;omoa
[)." 70.%-_ _ In~n
IJ GCMWTVTlenl
AJnded
• Out of Pocket
Allocative efficiency a 'iI ! 100.00% 80.00"" 60.00% 40.00% 20.00% 0.00%
Main items of pharmaceutical expenditure ---~-
--
.-~-
..- .. -----
c
w 'l;
~
- ~-: f'.\
ClFiji ,
60.%
.Marsh. Isld.
SO.% ,;
• Tuvalu
. I/J
j
'.
~W
•
~
..... ru
OCook
Islds
~<:;OQ~ If)
.~w;)j~l"'"
;
SMall'W
0 "&~"!> 1<.f-' X' il:' X' 1<-0 X' # X' Healthcare ReS)urce Groups ABCDGHJlMNPRSV
Annex 7
Equity issues
HCF strategy - Pacific
o Outer Islands tend to get less per capita share of any budget
o The approach of high public funding/low private funding is most appropriate
o Unmet need for diabetes treatment in Fiji: increased expenditure of ~200/0 is needed
o Need to find the means to assist small o Need a
countries with significant diseconomies of scale strong focus on effective and efficient use of resources
o Co-payments: are they more trouble than they are worth?
HCF strategy - Pacific o Understand government tax financing as II form of 'social health protection', 1Nith pooling and re-distribution to the poor CJ Targeting of poor and vulnerable communities is essential (e.g. mentally ill) o Advocatinp for increased government funding and effective use of resources requires national
Conclusions o Each country must develop its own Health Financing
strategy
C 5HI mechanisms are not sufficient to achieve unlversal coverage; tax·rundingle needed [] HeF strategy should focus on sodal hulth protection not just social health insurance D There i& a need to consider universal acatU not , ...t unlve..... covet'age o Gender I..ues need more attention needs of poor and vulnerable communities are essential
capacity building
o Targeting mechanisms that speclflcally address the
Annex 7
Health Financing issues in Asia and the Pacific:
SEAR and WPR have the highest levels of out-of- cket health ex nditures
1. Data on health spending from the MTR 2. Efficiency issues from the MTR
lOll" f' .... ""!'.nftu..
•• ,,,
n~"
.. LoIo...h ... ", .. '" •
oS.,wll 11111 i", ..,,,,. IT.
'n.,,",
uooa. .... '.OIIII
, / .i ~~
. ~,.
SEAR and WPR have very high rates of catastrophic and impoverishing household health care payments
Private health spending is more than half the total amount spent on health, in many of our largest countries Bangladesh 68% India 75% Myanmar Nepal Lao PDR Cambodia
81% 11% 56%
o irrpoverishrrent
• catastrophic
90% 64% 52%
Malaysia
/'
"" --...... ... , ",.an ",.an
/""
Philippines 65% Singapore
Sri Lanka
61%
"'.<m
China
55%
VietNam
61%
Nun'i>er of people (1 ,000)
Most Asia-Pacific countries have public spending on health less than 5% of GOP c:=JGovemment he.1th spending II % of GOP (Z001)
Low government health spending means high private spending and high out-ot-pocket expenditures
•• •• .,. "
-
-
-
guHc---------------------------
"
~12ft~~----------------------~ J10~~----~-------------------
" " u " " "
,: , ,
tllilllm~;~1 :
i
, ,
,
,
i !
•. t---~~------------~~---- > , • t--+---'-;:-'T,,=",;;:;;:;~ I & ~c",
l·~....o....L---- I ,t----=.-::.y;r.1;j:
i~~g~~~~~~~~~~f~j
z ... za: ..
:;;~~~8
i~
""""'" h . . lt~ upUdlluru aa '10 oftol.1
Annex 7
Purchasing and Financial Management 1. Decentralization: unequal revenue mobilization by local governments; difficulty tracking and monitoring financial flows. 2. Provlder payments: countries that use fee-forservice (CAM, CHN, LAO, PHL, VTN) have the highest OOPs. 3. Inefficient budget disbursement: delays, spending skewed to end of fiscal year.
Annex 7
Main findings [] While economic growth has been significant government health spending has not kept pace
[] Extensive poverty and excessive OOP spending remain the mo.t algntficilnt bamen; to accen
[] SHI PQpul.tlon coverage I. not reflected in levels of
ftnancla' protection
[] 5HI systems require capacity building and institutional
strengthening
[] Voluntary hutth Insurance schemes have suffered from
slow uptake, Umited risk pools and high drop--out rates access for the poor
D Targeted .ubsldies are most effective In providing
Composition of THE
- •f""----,----,
o Out-of-pocket spending is still the main source of financing o Government financing 15 not adequate
.--.......... :
o Social health insurance has not yet had a major impact on reducing OOP
o MongOlia performs the best on financial protection
J
-----.
! : I
i i
I
1--::_=-_-,-0_-+-----/
-""""'.--J
'.
Depth of universal coverage
LIC - coverage
o SHI share of THE does not match population coverage
o Must discount for administrative costs
o Cambodia, Laos and Viet Nam o The most immediate need is coverage o Main issues: • • • • Increased government spending Implementation of SHI Scaling up of subsidy and SHP mechanisms Changing disease patterns
o An accurate measure of financial protection is needed
Annex 7
Some countries have reduced OOP C~"I"
Private health expenditure in countries with low government expenditure
ill OlJl.Ol.fIoelcil .. "oITOIII HII/III bpallllllum,2GO!-
, ,
•
."
a" 0
QU
·ID
·
• •
"'
'1 .;;...
r -
.....-
LJ~
"' = n
..
• j
........ ............. ." r-
I 'i 1.5
1 0
<"
I
,... ::: I-I-L.-
"""
,
.....
." ~ ~
'" " ..
!tI,S-
!"
,;f
I-- I-"L.- L.-
Ii!
-I
~~
/
,l'
,~
.... .. "
,,/
l'q~<f<iI' t7/
- - -.. .,l ~
"i ~ " • • "• " ,
~
c::::::J'IIoolGGE "" "-I1tI .....1Io prj...... peMm....
TOTAL government and private health expenditures (THE) is also very low: Less than US $100 in 15 out of 38 countries, Less than US $35 in five countries ($35 is the estimated cost of a very basic package of health services, but it could be as much as $100)
Efficiency issues: resource allocation for PHC Due to growth of hospitals and high technology, few health resources are left for PHC and prevention .. 70%-80% of essential care can be delivered at
PHC level. .. non-hospital health expenses are 28% of the total In OECD countries ,. less than 20% of total health expenditurn on PHC in
VTN, PHL, MON, LAO, CHN, and CAM
,. AOe eatimated an average level of 1Q% In Alia
Resource allocation for health inputs
vvnere pnarmaCeUtlCa, expem",ures are high, out-of-pocket payments are also high Ph.rmil"elltl".llnd oop upendltll....... 'II.of tlllil h..nh ,xpendltll'.., 2005
Health workforce budget.
• • ,1........ 01_ ...... ..,."'•• 1' .. 0)01
are low, while expendltur•• on drugs and diagnostic procedu .... are high
••,_,....b,_
This usually means that providers are charging fees and earning their
salaries from medicln.. and tests
'=Ii .. ., ., "I! ! !!
:5.... ....IY .~
" " " ," !
I--
~
!
I
I
I
c.t.~
..
I
l=~ " , !.Iong<>io
I-~
f- . ff-
I--
r- I-r- I-I--
I-I--
ff-
-
<>.,
'Cambodia
r
La ...
Via! NIl",
1_1'hto'"",C811ti:a. _ ()y~of'1'oe""!
I
Annex 7
Health Care Financing Strategy: SEAR R.eview
South East Asia Region • • • 6.
B_ Bh..-
s.
DPR.1Corea. India Indona1a Maldives Myanmar
,.
HCFUnit WHOSEARO
• u..
N ....
• SriLanka ... , 11udland 11mOf'Leste
.. ..
OYer one-fourth oftbe world's population Poverty pockets Some of the poorest health indieatOl'S
..
SUlDID.I!l"Y financing situation C:o"'p_lti .... of~ .. t.1
Summary financing situation
he.lth sp."dlnll
h. SEAR
BOOf's • ..oeial insur.nee CpTivate huuTa .. ,," atax
="""'. ___. ___ to-,
___6", _ _ _ .._.. .-....=0.01.1_.. __
Summary financing situation
Summary finaneing situation
... ... ... ",.
TM~"
_
.. rlo ODP""
l !f-
"Neglect of social development • HighOPP - DOt a strategic rationing insttument but a barrier to access and utillsation • Inadequate government spending • Umited shift from OOP to co-payment schemes • Inefficiencies in resources use -large unregulated private sector - Jarge informal sector
. ..
I "
!
!
-g;;:
H Jil fl.! 1 1,1. 1'1 : ilfl-fl-l-i= 1 .,. . ,.. - - .. ... .. rl '. II -" ~
.--
~
Annex 7
Health Care Financing Strategy. SEAR Review Seminar on health financing SenIor ministry of health officials • DiscussJOD 00 country experiences with each of the financing sub-functions - collection ~pooUng
South East Asia Region: Recent policy
, • , , • , • " 11
,
· financing mechanisms - purclJasin& _benefit pa<kages · provider payments · contracting
• ......... T1woilMd
--. -.... .... - ........ ....- -c~"""
changes
e........ • h.....
1..."
..... (j
...... , , , • •
.......-
ca, 0
Not.,qollolt
-•
(Reatru)
DPRK...... II ..........1.
i
"' c....
• 0
iil I 0
MOII_""_
,
,
i_ItIllIQlldl
T\moJ't...a. NDt.apIIcM
• , , •
I'
Health Care Financing Strategy. SEAR review Financing mechanisms Government revenues ./ key source of equitable collection and pooling
Health Care Financing Strategy. SEAR review Financing mechanisms Insurance • Social insurance '" supplement government revenues and
resources for health in the SEAR region ./ ioclusion of prevention, promotion and rehabilitative services 'i' curative service
complement national policy goals (equity)
x inadequate volume x inefficiencies (allocation, stnlcture, flow of funds, purchasing)
x formal sector still limited (civil servants) x fragmentation • Private bumrance y"'toP up' for those who can afford 4
x regulation to limit the (cost) impact aD the
system
, Utre
l'mancmg :nrategy: SEAR review
Health Care Financing Strategy: SEAR review Purehasing
Financing mechanisms • CoDltn1lDity based initiatives (insurance, DSF)
v target specific groups
v access to specific SeMces x 'islands of success' within existing (weak) systems with limited potential to scaling-up
• Benefit packages • Provider pyments • Contracting PGtentlal to • Se~te financing and provisioo in ihe pubUe sector • Eft"ectively engage the nOD-state sector
• Userfees ? key issue in SEAR ? • Donor funding ., important for filling gaps/piloting new initiatives x volatilityfsustainability issues x donor harmonisation continues to be a problem
-Improve overall systems performance
Annex 7
Health Care Financing Strategy: SEAR Recommendations for Review - Context of tlnandal aisis (Regional Coosultation) - More debill on the F'1mctional Stratesles _ fbuuldng mechanisms" sociaJ. pI"Otec:tiOD through •
-purchasin( - Link to pbarma and service delivery (health systems) - Elaborate on fiseal issues and 8nandalllWlllgeDlent - Fbtr; 'p-ound-Ieyel' donor hld'mouisation issues - Identify Imowlcdce pp.s - fllchIIcht reqUisite changes In role of state (Dmuition.~ and p'ro-acti.W! links between approaches and desired outcomes, inCluding beyond health) - (Advocacy)
......
-
-
ANNEX 8
THE HEAlTH CARE FINANCING STRATEGY FOR 2010-2015
Universal Coverage Breadth of coverage: most of the population has access to health services Depth of coverage: availability of essentIal health services (preventive, curative, and rehabilitative) Is available Height of coverage: most of the costs are covered through prepayment; out-of-pocket payments are low.
Universal coverage Out-of-pocket payments Global evidence Target Indicators Strategy framework Strategy areas
" /~~--.
Steps towards Universal Coverage i Una.... l~
~../"
'l
Tl!,"I"'L\r:~!IIiII'C-'l;
.,0_ ~~~~~;~;:~~~r:-~"
, ,""';'1
",-" I-",ilh W'J1f,.1~H
LIuIliiR~dlatlUlIlJCilll~ ,,' thr-"' .:nll'\l,'IiIy • t.,::er.~,'.ISI' ~-~tt.1 G~,~ :"<11'." ,'!01.- '-... , '.1:..:rl:oIIllor ,~c ~AJ! ""I"':' IU·,.lI;.J.;rJ.';':;' l<.jl~ <!ool '1~ t•.,,·.~·· ,;-r.:r-,!
t
. l.u',.:',.: ~....~ .:1:'.'1""
~. "'1'iIMrJ ....... Can: N..... ___ Tl\an EWI', World HN/Ih Report2OO8, WHO.
;
.
.. ~
~
I
~111"-4>J"l,:~_e :I:rfI~·jW
Sourw:
wI·~.,wu 'mT~I~~
Countries where a high percentage OT nealtn expenditures is out-of-pocket have high rates of household ImDoverishment 1'............. of h"..... hold8 with cu. .. tI.'Opblc "pondltu... o ~&. o .... -<I( p;oy ....... t in _ I b..llb. e,.-p.ndlhl. ...
poc"'"
~h.a ..... (
P-~"tlo&~ <Of "o ... ~It."ld. ""p,,~
plI)'ment In",t.U b...,1I11.
.... j .....~ vo_ .b... ~ of <>u;..o! p".-1'~1 "",p<'n~!~
,.
t: j:
t:
..
.• ODP",THE
... . . O<".~ "'.
-'~.~.~~~.~~-~~--.-~--.-~
Annex 8
l;ountnes wnere government nealtn expenditures are low have high rates of household catastrophic expenditures :re..,nta"" at Ito" ... h~)d. with ,.ra"""piU< ""'pomditure' " .. ~~etnm""l
Health financing target indicators Global, regional and country specific evidence suggests
h ... hne"<"""dlhl,e u •• bue nf GDP
that universal coverage I. attained when: Out-ot-pocket spending should not exceed 30..40% Total health spending should be at least 4--5% of GOP with 50%-70% of public financing Over 90% population covered by risk pooling prepayment schem.. ; and Almost 100% coverage of vulnerable populations with social assistance and aafety net aehemes
I I I I
I.
How applicable the target indicators? Countries Korea(RO) Malaysia
Financing Universal Coverage PUBLIC FINANCING
THE .. %of
OOP""'of THE
R........
GOP 6.6
43.3 55.0 67.0
Co-payments
4.' 3.2
Prtvate sector, but all covered by taxation_ Family level savings that covered atl. Nearly all poor and vulnerable covared LOW COP
Singapore Thailand Cambodia Mongolia
3.' 5.' 6.2
33.0 71.0
Low risk pool and no cover of vul .....b.. Both SHI and tax CO~
<10m""""
payments, dla'gH, AlPporUng pttvaIt
ReSlclna 'HI, co-
.,,"""'"
25
PRIVATE FINANCING
vulnerable
""'-0: NlA2OO1--. WIfO
- --"'" -~-~~~fees.co
1Chemft, !all and SHI
HIGH
peymantS & con'lltfting
""",..."
Strategy framework
--{ ... ......... ~~.-
GOlIII5/0utcamu
--ftwpoowl,w_
,-
I
-,-
SocIal & fInIonct.l rtI.II
",
~-
ImptWHIIIIlde"",
I I
'1 _ _ " .nd~~ • 1m.........'"
......... -.... ...-.. . I _......... ~
.
.1mprD... _ _ _~k>r
_pool"lll .............. ptO\lIdIIf ""~
aff__ 'ImpfO"'~
..... _ .
. Impn;>_ ..... """';ng
po..,. .......
~
'~I_IIr. ...... _ v
I .... nno_' I'Pr<I....f\ooOu ... --..tia.... Iy ...... 4..-_ _ ..... 1 ........... ) .....h _ .... paIIa, _ _ ~
--,..I:.'"'''''''''''_1IIIIIy .....
nat macha......
.~..,..y
."" .....1......... 01 paliay ehangooo (pUI'~_""1
__
ANNEX 9
PRESENTATION 4.1 HEALTH FINANCING STRATEGY AREA 1 AND ACTIONS Increase Investment and public spending on health With Strategy Areas 2 and 3, increasing Investment and public spending alms to support countries to ensure adequate financial resources for the health sector while increasing overall efficiency gains and Improving aid effectiveness. This should Increase the availability of essential and quality health services and products and perfonnance of the health workforce.
Strategy Area 1: Increase investment and public spending on health 1. Enhance government commitment to universal coverage 2. Produce policy briefs on increasing government spending 3. Strengthen national capacity for resource mobilization 4. Provide evidence for Increasing heatth spending during the financial crisis 5. Increase awareness of beneflta of pubUc spending of hearth wtth CGllaboration between health and other ministries 6. Mobilize resoLrC8lli from International partnel'$hips for hearth plans and social safety nets to meet poverty red'uctlon goals 7. Com~ health ~ needs for universal coverage wtth CllT8nt provision, IdentIfY gaps and the costa of fliling them 8. Health workforce development plan wtth compensation levels based on living costs and public sector salaries
PRESENTATION 4.2 HEALTH FINANCING STRATEGY AREA 2 AND ACTIONS Improve aid effectiveness This will support increased aid and Its effective use to
Strategy Area 2: Improve aid effectiveness 1. Revl.. national targel$, ~.ns, sc;tions and resource requirements badl:ed by casted and velldated country health plans Needs assessments to identify systemic constraints and im~ementatlon botttenecks fur the delivery of essential services 3. CapaCIty development linked to policy .nd Institutional needs, coordinating with other II8CtoB and partncn 4. Reduce fragmentation by improving coordination of domestic and external resources to attain health policy goale . 5. Ensure donor supported activities and programs are aligned with government programs and plana. 6. Enswe consistency between health sector davetopmant plans,
2.
improve population health outcomes by attaining universal coverage. Domestic flnanclng of health systems is the best choice, and should be based on rlsk-poollng, taxes or be insurance based. External aid will continue to play an Important complementary rote. especially in low~ income countries.
:=~~~ :c:r':=C::r!~f~::!!::'Bet, considering other
7. Increase proportion of aid that can be programmed by the MOH and general budget support, transparency and timetlneM of information on financial aid. B. Work with partners 10 increase duration of commitments and reduce volatility to ensUl"a smooth funding over lhe course of the year
PRESENTATION 4.3 HEALTH FINANCING STRATEGY AREA 3 AND ACTIONS Improve effiCiency by rationalizing health expenditures Better use of domestic and external resources is needed to maximize the Impact of all investments In health, whether existing or new, and address current problems of Inequity, Inefficiency, and poor qualtty of services. Cost-effective primary and public he.lth Interventions can be starved of resources where financing is biased towards hospltal-based curative care.
:mategy Area ,,: Improve emclency oy rationalizing health expenditures 1. Improve haalth NCtor administration and management skills 2. Improva national platlnlng PI"OC8S$U, by using MTEF and oilier tool. 3. U.e public health expenditure reviews and ....ults-b.sacl budgeting to attain greater aftIciency from public spending 4. Improve budgeting and financial planning Pl"llctlces to ensura emclent and equitable allocation offlnanclal resources 5. Budget dlsburaement monitoring to ......r. PHC faclllUas racaIve funds. 6. Review t.rtiary hospital expendltu.... to find possibla areas of cost uvlnp.
8. Stranathen regulation of the prtvate nctor lind enable the private sactor to
7. ~=::=~:.rm~=t~C!=r~~~~ ~~e:~~:~,,~uca out-of-poCket payments
partlcTjMta In delivering primary health car•. 9. Innovatlv. approochu to support rational usa of clrug. atlel technologies. 10.lncreua health worldotce motNaliOn by analyalng Alary IaYaIs and perform.nce baaed flnaltCiallncentIvU for hUlth workfOrce. 11. Discourage unethical health workforce behaviours with evidence to minimize recession, promote
12. ==-:nm=~U:.a~r:::=;Oc'::~~!:a1
13. Negotiate WIth unloM and staff, develop initiatives to promote homa-basecl can! and other servI.... for the etderIy and the most wlnerable.
Annex 9
PRESENTATION 4.4 HEALTH FINANCING STRATEGY AREA 4 AND ACTIONS Increase prepayment and pooling This alms to Increase rlsk-poollng and prepayment to Improve protection againlt flnancial risks of using health care services and unpredictable health caf. costa. Pooling has Impacts on health car. coverage, coll.CUon of revenue., allocation of public resources, service provision, purchasing and health sector governance.
Strategy Area 4: Increase prepayment and pooling 1. Advocacy and public Information for policy commitments to universal
ace....
2. Gen.rate eYklence on financial protec:tIon aplnlt catutrophlc and
Impoverishing health payments. p~t option5 Including 50cllll health insurance schamas. 4. Cost defined health pactages to advocabl universal coverage by showing that bMeftts are sustainable from pooled funding 5. ActIon planl to Increlse population coverage IUld ace.n to essential and 3. Defina approp1ate
quality "ealth servle.s ItIrough prepaymllrlt mechanisms
I. CommunicatiOfl .trategies for p....,ayment and pooling supporting unlvwllll covetage and acetlll to qualil¥ h.alth sarvlces. 7. Increase undllfStandlng of pntpf;)'ment and pooMtIg by health wot1cforce and . .datsh:lp to mana.a resources afJecttvaIy and deHvar quanty health care. I. CapKHy to purc:hua and deliver quaUty health • ..-vic.. supported by norms and acc:tedltMkMl mech. .lllms.
PRESENTATION 4.5 HEALTH FINANCING STRATEGY AREA 5 AND ACTIONS Improve provider payment methods The purchasing function detennine. which interventions should be purchased In response to population needs, and cost effectiveness, how they should b. purchased and from whom. Provider payment I. an essenual component of purchasing that aims to Improve health system performance through effective allocation of financial resources to providers.
Strategy Area 5: Improve provi.der payment methods 1. Evaluilta current p'rovlder payment meltlod. and Impacts on health system performance and financing. 2. Ensure frH access to PHC health service package uling global budgeting. salaries and capitation payments. 3. ~:':~~du::.:::.iIt complement health workers . .Iarid by cia... 4. Incl'NH consumar awareness about provldar payment methods. 5. Dlaoou,. feu for srtIces ttl. Gan affeGt cata.strophK: hnnh spandln •.
6. RHb'iet providers' ability to establish own fees and charges.
7. ::=~~:".~=~:,~anted payment mattlodl,
t. Battar UI. of financial resourc.. through altemaUv. provlcMr fMymenl mathocis auch as DRG, ReF, and P4P where fUsible. 9. Montlor ehet:I of prcMcNt payments under pooled flnancWl81)'1Wms rallttva to policy otIjacthtes to reduce out~Mt; payments. 10.Alllgn unit ill MOH or SHl.I{tefICles to hah.. a. and Introduce provtdar PlI)'I'IIllHlt Med'loQa with avldencHaaad .w.n..,.. over fM..foi' ........
1"~=:n~,t:~~mC:I:::lno::::=~r::::,~ p.uclpa1e In
PRESENTATION 4.6 HEALTH FINANCING STRATEGY AREA 6 AND ACTIONS Strengthen safety-net mechanisms for the poor and vulnerable The strategy will support actions to ensure universal coverage and access to necessary health services by removing financial barriers. The main focus is reduction of OOP. The region has experiences wtth targeted subsidies for Insurance premiums and h08pltal fees, and communlty-bued health Insurance.
Strategy Area 6: Strengthen safety-net mechanisms for the poor and vulnerable 1. Deva&og and implement POlin: options to strengthen safety nets for r~l:.l removing financial arriers In publicly owned health
2. Improve country-fevel data on the major forms of oaP expenditure. 3. lmprove method, to estimate Impacts of OOP on different income groups to design effecttve beneftts for the most needed vulnerabkt papulat50n. ... Antlyse hulth spending patterns at poor and vulnBnlbl. groups including on pre_nti_ servicH which may be unaffardabkt. 5. Review and au... til.,. regulations and practices and their Impaets on acc..., equity and poverty. G. Sttangthen the ra.aulatory framework needed to dill" u"lv'~ll eov....g. and proYkte effective social safety 11811. 7. Evehaete and Implement pramlwn subsidies, user fH uempUom', conditional casli tn.nsfen. and other sodal _ietenta sctMwnes for poor and vuln81lble groups.
'eel
Annex 9
PRESENTATION 4.7 HEALTH FINANCING STRATEGY AREA 7 AND ACTIONS Improve evidence and information for pollcymakin9
::>tratagy Area I: Improve eVlaence ana information for policymaking 1. Promote evldence..o.a..d policy and action by studies on macrOlconomics, cost-effectlvenes. of health InteMlfltJonl, afld h.alth impacts of til, global financial crisis. 2. Establish antkrisla unit within MOH to coUecI and analyse r.aHme data to
respond rapldty to ',dllce possible health impact..
ThiS will support strategic actions to Improve data and Information on financial Inputs and allocation. health outcomes, and flnanclal management. to support public spending on health, prepayment and pooling of resources, and strengthen safety n8t mechanisms.
3. Improve llealth financing information using nadonal and sub-natlona' health accounts, Internl110mlll standarlis and cl •• slflcatlons. 4. improve date .....II.blllty end quality following international,tandardl and praetiea on natlonll hulttllcca.unta.
5. Provide II..Utl pl)liq rue.retlars wtItInlnlng. tergated '''''Areh topics, and flnanclalluppor1 to providalnfol'1l\Mion to polley makers, officials, and civil society grouJK. 6. Studies and dl8logu" on reorientation of haallt! services and r.a/locatlon of financial r.souTCeIJ for universal COYlfIIgl.
7. Review eJdating atuell.. of health equity and hlalth financing and analyze causes of Inequitable financing thl'GUgh robust health indlcato.... to Improve equity and ICCUS to health servicil.
PRESENTATION 4.8 HEALTH FINANCING STRATEGY AREA 8 AND ACTIONS Improve monitoring and evaluation of policy changes
Strategy Araa 8: Improve monitoring and evaluation of policy changes 1. 2. 3. 4.
Strengthen natlon..1capadly for monitoring and evaluation ldetltlfy Informatlcm requirements and gaps in managerial and analytical skills. Train staff h . .tth economics and Implementation and monltortng of healltt financing pOlicies. ~-:::==dng indicators Into overall haatlh monitoring and
'n
Policies. Interventions. and strategic actions will need to be adapted to specific counbies. and monitoring progress in Implementing the strategy should be done
So 6.
Foc:us on mof't I~t outcomaa and report OOP lev_ for an pal1s of the hNIIh sys1Im IrI a altlely ..a"ner. Transfonn h,.,.,. flnallclng evaluation results into eIfective hOllth policies
at regional and national levels. Monitoring Indicators should be politically relevant as well as technically useful, and the number should be kept to a minimum, and be uniform so progress can be compared across
7. 8.
:::Hc:n-t:~~~~"=~fI~':;~n';-::'~to~= ~:'~~ne ;~::~ ~~!~~f~~..:o=. other groups doing monitoring and Provide timely repol1s based on NHA data to health planners to track resource allocations 10 PHC.
9.
the region.
ANNEX 10
What does "strategy" mean? Summary of discussions ~
on the draft Regional Strategy Day 2 ~
The science or art of planning and directing large operations Skilful management of any kind especially by using stratagems. objectives and methods
OBJECTIVES ~
BREADTH, HEIGHT AND DEPTH Policy-based actions
Reduced OOP spending and Increased public funding ActIvities will be country specific Mixed tax-funded and pre-payment system Strive to achieve the proposed targets How to encourage governments to reach the objectives?
~ ~
v.s. Quantitative measurement
~ ~
OBJECTIVES vs. ACTIVITIES ~
CORRECTIONS ~
Need to separate the objectives from the proposed activities to achieve those objectives Distinguish between 'levels' of activitles
Notify WPRO of any necessary corrections
~ ~
Make definitions dear and consistent Use consistent measurement of THEOfoGDP, GHEOfoGDP and GHEOfoBudget otdtIrlntI MIl rest:ruc:turlng oIthe amtent oIeach
~
--, -~
Annex 10
CROSS-CUTTING ISSUES • Provide a framework for theSe in the Strategy • Recognition of the role of dvil society organizations: support from the public and NGOs
AREA 1: Public spending • Recognize the need for advocacy to policy makers • Need to quantifY required increase in government spending • Mobilize local as well as national resources
AREA 2: ODA effectiveness • Could be based on the 5 pillars of the Paris Declaration
AREA 3: Efficiency .. Main question is 'value for money' • Focus on mllior categories of expenditure • Requires cost analysis on which to base policy .. Need to emphasize positive incentives • Need to consider demand-slde issues
• Base ODA activities on national plans .. Particular issues related to IHPs like the Global Fund: improve domestic capacity
(access, adverse selection, perverse incentives) as well as supply-side • Account for relations with the private sector
AREA 4: Pre-payment and pooling • Distinguish between 'pre-payment' and 'risk-pooling' • Need to consider 'sufficiency' of the benefit package; and equity considerations
AREA 5: Provider payment .. Clearly define the role of fee-for-service methods and other categories of provider payment • Consider quality of service as well as cost containment • Use provider payment methods that encourage adequate provision of services and promote access .. SEARO: 5 main areas of concern
Annex 10
AREA 6: safety nets .. Empower the poor and vulnerable to attain social health protection .. Include options for safety-net mechanisms .. Exemption systems must be funded
AREA 7: Evidence for policy .. cannot make effective policy without reliable data .. Establish standard NHA where tlley do not exist .. Need to develop capacity to create accessible database of health financing information (including BOD) .. Give careful consideration to the use of the data
AREA 8: Monitoring and evaluation .. Base Mr.E on timely NHA reports; with supplementary data (benefit incidence) .. Accountability and community aspects are important
CONCLUSION .. Table of country achievements to date .. Promote the strategy In the national and regional context.
.. Adopt tile monitoring indicators as listed (with country-specific programs) .. MIlE requires specific budget