(WP)HSD/ICP/HRF/6.4/001 Report series number: RS/2003/GE/03(PHL)
English only
REPORT THIRD HEALTH SECTOR DEVELOPMENT TECHNIC AL ADVISORY GROUP (HSD TAG) MEETING: HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION
Convened by:
WORLD HEALTH ORGANIZATION REGION AL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 17-19 February 2003
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April2003
NOTE
The views expressed in this report are those of the participants in the meeting and do not necessarily reflect the policy of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office in the Western Pacific for those who participated in the Third Health Sector Development Technical Advisory Group Meeting: Health Care Financing in the Western Pacific Region which was held in Manila, Philippines, from 17 to 19 February 2003.
CONTENTS
SUMMARY ....................................................... ................. .... ................ ............... ..... ..... ............. 1 INTRODUCTION .............. ......... .. ..................................... .............................................. ........... .. 3 1.1 Objectives ............................................... ......... ................... ..... .... .................................. 3 1.2 Participants .................. .... .. ............ ..... .................................... .. ........ :............................ 3 1.3 Organization .................... ............................. ............. ....................... :................... ...... ... 3 1.4 Opening ceremony ............................ ........ ................... ............... ....................... .......... . 3 2. PROCEEDINGS ........ .. ......... .... .................................................. ............. ........ ..... ......... ........ ... 4 2.1 Overall Health Situation in the Western Pacific Region .............................................. .4 2.2 Regional Overview on Health Care Financing .............................................................. 5 2.3 Country Presentations: Health Care Financing Issues and Challenges ......................... 7 2.4 Presentations on National Health Accounts (NHA) .................................................... 13 2.5 Health Care Financing Theme 1: Revenue Collection ............................................... 14 2.6 Health Care Financing Theme 2: Pooling Financial Resources ................................. 15 2. 7 Health Care Financing Theme 3: Purchasing Health Services ................................... 17 2.8 Summary of Key Issues Raised (from paper presentations) ........................................ 20 3. OUTPUT OF WORKING GROUPS ..................................................................................... 22 4. CONCLUSION AND RECOMMENDATIONS ................................................................... 31
Keywords: Health care fmancing I Health.care reform I Revenue collection I Pooling of fmancial resources/ Purchasing of health services I Western Pacific I Philippines
SUMMARY
Health sector development is one of the major areas of action identified for the Region. There are four areas of focus in health sector development. These are: health sector reform; human resources development; health information and evidence for policy; and emergency and humanitarian action. Under the health sector reform focus, health care financing is identified as a major theme that needs to be prioritized. With this increased emphasis on health care financing at the national and international levels, WHO should define its role and " identify strategies towards health care financing policy development in the Region and provide appropriate health care financing policy advice and guidance to the Member States. The Third Health Sector Development Technical Advisory Group Meeting conducted from 17 to 19 February 2003 had the theme "Health Care Financing in the Western Pacific Region." The meeting attempted to contribute to the process of defining WHO's role towards health care financing policy development by reviewing the current situation, identifying main challenges and recommending strategies and specific action steps. The meeting had three major activities: (1) overview of the health situation and health care financing for the Western Pacific Region and some of its Member States; (2) paper presentations on Key Themes That Have an Impact on Health Care Financing; and (3) working group discussions to identify issues, identify collaborating partners and suggest recommendations for WHO's Western Pacific Regional Office on how best to pursue health care financing in the Region. Several cross-cutting issues and challenges in health care financing were identified. Among these were the observations that out-of-pocket spending still accounts for a huge share in fmancing health and that the emphasis in health care financing continues to be along the curative aspects of health. National Health Accmmts are seen as playing a major role in the further development, monitoring and evaluation of health care fmancing. There is a need for information and a systematic way to access data to aid in decision-making. Moreover, there is also an increasing realization that issues on health care financing carmot be discussed solely by the public sector, particularly Ministries of Health. Health care financing goes beyond the delivery of health services and is a key issue in the domain of politics, economics, finance and culture, among others. Several important strategies were identified by the three working groups. These recommended strategies are envisioned to help in giving more concrete directions to enable WHO/WPRO to assist and support Member States in pursuing health care financing initiatives. A key strategy involves changing mindsets and expanding the dimensions of health systems to encompass a broader and wider defmition of health care financing and its three main areas -- revenue collection, pooling of fmancial resources and purchasing of health services. A broader view is required to review and formulate the appropriate policies. Also, networking and partnerships among different stakeholders within and across Member States is necessary. Furthermore, because of this new paradigm of understanding health care fmancing, there is also a need to raise the capacity levels (knowledge and skills) of different players within the health sector, starting with the Ministries of Health as well as other branches of government and the private sector. Thus, training and capacity-building programmes should be crafted. This will require adopting a more systematic process of studying, documenting
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and accessing all relevant experiences and information on health care financing from the different countries within the Region as well as from other regions. Finally, specific recommendations were suggested by the three working groups on particular areas of action that the Western Pacific Regional Office could focus on to further the work on health care financing. These recommendations revolve around three general themes, namely: (1) policy studies, research and documentation, including pilot implementation of schemes; (2) capacity-building; and (3) networking and partnership building, including advocacy. Specific ·recommendations were put forward for these three themes as they relate to the health care financing theme discussed. The way forward, therefore, requires that recommendations be re-visited, existing studies be reviewed and new research conducted. These activities will accelerate the creation of a Regional Framework on Health Care Financing, which can then be used as the guide by the Western Pacific Region's Member States.
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1. INTRODUCTION 1.1 Objectives
The objectives of the Third Health Sector Development Technical Advisory Group (TAG) Meeting on Health Care Financing in the Western Pacific Region were: to review the current situation, main challenges and options to strengthen health (1) care fmancing arrangement in the Member States; to identify regional strategies with regard to health fmancing an<;l its three main (2) areas, namely, fund collection, pooling and purchasing; and to provide recommendations on priority health care financing issues and policy (3) development in the Region. 1.2 Participants
The meeting was attended by TAG members, temporary advisers, resource persons, observers and Secretariat members. The Regional Director suggested the following roles and they were approved by the participants: Chairperson Vice-Chairperson Rapporteur Dr Phua Kai Hong Ms Frances Brebner Ms Maylene Beltran
The list of participants is attached as Annex 1. 1.3 Organization
The Third Health Sector Development Technical Advisory Group Meeting on Health Care Financing in the Western Pacific Region met in Manila, Philippines, from 17 to 19 February 2003. The agenda and programme of activities are attached as Annexes 2 and3. 1.4 Opening ceremony
Dr Shigeru Omi, Regional Director ofWHO's Western Pacific Regional Office formally opened the meeting. In his opening speech, Dr Omi affirmed that the topic of the TAG Meeting, health care fmancing, is very important and fundamental. Moreover, he recognized its complexity and its widespread implications within and outside the health sector, specifically its direct and indirect links with other social objectives in the arena of solidarity and social protection.
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Dr Omi stressed that health care fmancing contributes to better health by mobilizing resources to deliver essential health services to the entire population, especially the poor and marginalized. Health financing is defined as one of the core components ofhealth systems and health sector reform in the Region. Because the issues and challenges in health care financing are diverse, it is difficult to arrive at a single, common answer to questions that continue to be raised. Health financing priorities vary from one country to another and range from resource mobilization to cost containment. A common challenge in many countries is how to determine and establish a stable, efficient and equitable system of mobilizing resources to deliver and make essential-health services available. This requires policy makers to make decisions in terms of the most efficient methods of resource mobilization, resource allocation and utilization. WHO support to the Member States has increased in the recent years through the conduct of country-specific assistance for policy reviews, the provision of technical support in terms of helping to determine the most suitable financing arrangements, in designing community health insurance projects and in setting up the National Health Accounts. Although these efforts have reaped significant results, Dr. Omi stressed that an appropriate regional framework that will concretely articulate on-the-ground strategies and recommendations will be very useful in guiding the work ofWHO in light of modest economic growth and scarce government revenue in many low-income countries. 2. PROCEEDINGS
2.1
Overall Health Situation in the Western Pacific Region
A brief update on the overall health picture of the different Member States was presented by Dr Soe Nyunt-U, Acting Director, Health Sector Development, WHO/Western Pacific Regional Office. The following were key observations and insights about the overall health situation in the Western Pacific Region: • There is great diversity in health picture among Member States. There are wide gaps and disparities; some Member States are in better conditions in terms of health outcomes (life expectancy, infant mortality rate (IMR), maternal mortality rate (MMR)) and others have problematic health outcomes. A key challenge that confronts the different Member States is a situation commonly referred to as the double burden of disease. Countries are faced with the challenge of continuing to prevent and lessen the prevalence of infectious diseases while having to deal with increasing incidence of chronic and degenerative diseases. Tuberculosis (TB) continues to be prevalent among high burden countries such as Cambodia, Mongolia, Papua New Guinea, the Philippines,
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VietNam, Lao People's Democratic Republic and China. The Stop TB Project, a special initiative, is now being implemented in the Region. • There is a declining incidence and drop in mortality rates for malaria among countries in the Region; however, country-specific performances for malaria eradication and control vary from minimal to advanced progress. Reported cases for.HN/AIDS in different countries are steadily increasing. There is a high prevalence rate of diabetes mellitus among low-income countries, ranging from 10% to 40%. It entails the delivery of costly tertiary care and referral to more sophisticated health facilities. Developing countries from the Region are undergoing rapid epidemiological and demographic transitions that bring about enormous health consequences.
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2.2
Regional Overview on Health Care Financing
To focus the discussions on how the Region is thinking about the role and contribution of health care financing in the overall effort of health sector development, Mr. D. Bayarsaikhan, Technical Officer for Health Care Financing, Western Pacific Regional Office, presented a broad overview on existing efforts, challenges and support provided to the Member States. WHO's conceptual framework on health systems has clearly defined the main functions of health financing. Health fmancing is divided functionally into three main areas, namely funds collection, resource pooling and mechanisms of payment relating to purchasing of health care services. This conceptual framework facilitates a better understanding of different health fmancing mechanisms and managing health financing implications effectively within the ongoing health sector reform process. The following were some of the important points raised: • There are four major sources of health care financing: government taxation; health insurance; private out-of-pocket payments; and external funding. All countries in the Region rely on a mixture of these financial resources. There are, however, significant differences in the emphasis countries give to each of these funding mechanisms. Efforts should be made to maintain or increase the public sector's role in fmancing health services while decreasing the financial burden on individual households through less out-of-pocket payments and private contributions.
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Health insurance based on fund pooling and risk-sharing principles is now becoming the best alternative financing option that the Region wants to propagate. National expenditures for health as a percentage of Gross Domestic Product (GDP) in Member States range from 3% to 11%. However, per capita health expenditure is still lower than US$ 35 in many countries of the Region. Health care financing goals for the different Western Pacific Region countries include: )> )> )> )> )>
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Achieving universal access to basic health services Ensuring frnancial protection by sharing funds and risks Equity in frnancing proportionate to income Financial sustainability Effectiveness of resource allocation and use.
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In light of these goals, what is the state of health care financing in the different Western Pacific countries? )>
There is a general reduction in public frnancing as a share of total government budget and in the total health expenditure. A noticeable increase in the share of private, out-of-pocket spending is apparent in many countries. The poor are paying a higher share of their income for health. Concomitantly, unplanned costs of health care lead to deepening and worsening poverty, especially in low-income countries. Financial sustainability is difficult to ensure, especially in countries where external funding sources for health occupy a significant percentage of the general government health expenditure. There is evidence of misallocation of meagre health resources leading to inefficiencies and lack of effectiveness. To wit, government spending in most countries continues to be skewed to hospital care; preventive and promotive health programmes are chronically underfunded; demand for certain types of goods and health services are supplier- and provider-driven; and offshore referral costs are high, especially in the Pacific Island countries.
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The National Health Accounts (NHA) presents a body of integrated information on health expenditure that allows analysis leading to effective policy formulation and implementation. The Member States are in varying stages of development in relation to theNHA. In light of the various challenges and issues that health care financing faces among the Western Pacific Region countries, there is a need to develop regional strategies and recommendations for action along three main areas ofhealth financing: collection of funds; pooling of resources; and purchasing health services.
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2.3
Country Presentations: Health Care Financing Issues and Challenges
Proceeding from the regional overview on health care fmancing, the TAG members presented a brief description of the main issues and challenges that they face in relation to fmancing health care services in selected countries. 2.3.1 China (presented by ProfShanlian Hu, MD, MSc, Professor, Training Centre for Health Management, School of Public Health, Fudan University) • Two factors were cited as contributing to the development of health fmancing issues that China faces today: • The transition from a centrally planned economy to a market economy; and • A shift from a formerly government- and community-funded health care system to one that is based on user charges. • China faces four main issues in health financing: escalation of health care costs; irrational structure of health revenue; inequity in financing health services between urban and rural China; and lack of funding for public health and health research. In light of these issues, China faces the following challenges in health fmancing: resource mobilization for public health; improving efficiency of health services; establishing a framework of public finance; and increasing the coverage of urban medical insurance and rural community fmancing. All of these challenges can only be addressed if government improves its functions towards more long-term health planning and regulation, taking into consideration the various components of health reform and its impact on health fmancing.
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2.3.2
Fiji (presented by Mr Luke Rokovada, Permanent Secretary for Health, Ministry ofHealth) • Health financing is considered a key component towards achieving the country's national health objectives. The implementation of key strategies, such as developing a viable national health insurance scheme, revising fees and charges towards costrecovery, forging stronger regional intersectoral collaboration and effective decentralization and reviewing legislation are still in their early stages of development. Some financing options are now being considered towards institutionalizing most suited health financing arrangement in Fiji. To wit, • Increasing general taxation revenue; • Exploring implications and consequences of implementing user charges for health care services; •Implementing pre-payment schemes in the form ofhealth insurance; and • Sourcing external funds. • Several necessary next steps have also been identified to move this initiative forward. These include: conducting the necessary research to determine costs and assess levels of interest among stakeholders; identifying the development partners and doing advocacy and lobbying for support among legislators; identifying national government partners; and taking stock of the risks and possible opposition.
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2.3.3
Republic ofKorea (presented by Mr Kyung-Tae Moon, Deputy Minister for Planning and Management, Ministry of Health and Welfare) • In the Republic of Korea, all citizens have health insurance under the National Health Insurance Scheme, which covers 96% of the population and the Medical Care Programme for the very poor, covering 4% of the population. After experiencing a robust fmancial status of health insurance prior to 2000, health insurance profits and reserve funds started to manifest a downward trend. This was attributed to the increase in cost of health care and the weak fmancial contribution of the self-employed sector. The rise in medical costs was brought about by several factors:
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• An increase in the use of medical services due to an increased life expectancy and an expanded benefit coverage. • An "induced demand" for medical services was brought about by an increase in the medical work force and health care institutions as well as the influence of the fee-for-service payment mechanism for providers. • The separation of the prescribing and dispensing function for health providers also contributed to the rising costs and the deficit in the finances of the health insurance programme. This also led to a decrease in the co-payment rate by the insurers. • Due to the dramatic fall in finances, a five-year plan to ensure the financial stability of the National Health Insurance System is being implemented. This plan is directed toward revenue generation by raising the contribution rate and controlling expenditure. • The financial stability programme includes strategies relevant to the government, the insured members, the health service providers and the insurers. 2.3.4 Malaysia (presented by Dr Rozita Halina Tun Hussein, Project Consultant, Malaysia National Health Accounts Project) • Currently, the health sector of the country is confronted with the following issues and concerns: • There is over-dependence on government health services, leading to a heavy workload and long waiting time in accessing health services. • There is little integration between public and private sectors. • There is an increasing demand and expectation for high-tech equipment and facilities leading to a corresponding increasing in the cost of medical care. • The Malaysia health situation is undergoing changes in demographic and epidemiologic patterns. •Increasing costs ofhealth care lead to greater inequity and can lead to public unrest if not confronted. • Globalization and liberalization trends pose challenges to the health sector as well. • The implementation of health sector reform in Malaysia had already been articulated in the Fourth Malaysia Plan (1981-1985) and is once again highlighted in the Eighth Malaysia Plan (2001-2005). The need for
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implementing a national health insurance plan had been articulated by the Malaysian Prime Minister in October 2002. • Yet despite all of these, the plan has not yet taken off and the national health insurance plan continues to be in its infancy stage. The following are factors cited for the delay in the implementation of health reform and national health insurance: • Decision-makers do not yet buy-in to the rationale and need for national health insurance- "If it ain't broke, why fix ,it?" There is a need to understand and expand knowledge on tax-based funding, social insurance, and the medical savings account. Since Malaysia is launching the National Health Accounts System, there is a need to enhance the capacity to fully utilize the NHA in policymaking and directing health reform planning, implementation and monitoring. The role of the private sector is recognized, however, networking and linking with them often does not fall under the jurisdiction of the Ministry of Health. There is also a need to upgrade and fortify the skills and capacities within the Ministry of Health for regulation, fund management and other necessary functions that health sector reform entails.
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2.3.5
Mongolia (presented by Dr Sodov Sonin, Executive Director, Health Sector Development Programme, Ministry of Health) • A primary issue confronted by Mongolia is the decreasing health expenditure as a percentage of GDP coupled with effects of inflation and a negative GDP. Allocation of health funds is skewed towards hospitals and curative services where most of the funds are channelled more to the provincial and urban hospitals and lesser to the hospitals in the countryside. In terms of delivery, a high number of hospital beds are maintained per 1000 population indicating inefficiency. Moreover, the country has an oversupply of doctors although there is also concomitant maldistribution so that there is still a shortage of doctors and nurses in the rural areas. In addition to this, there is a shortage of modem equipment, poor buildings, and shortage of nurses.
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A major challenge is to shift the allocation of funds from curative services or hospital care to primary care and preventive care. This entails the involvement of primary care and family group practices that can ensure a more rational allocation of limited funds. The Mongolian Health Insurance Fund aims to provide universal health care coverage to the entire population. The challenge is how to ensure that all members are covered by the health insurance, especially the poor and the nomad population. There is also a need to shift the focus to health promotion and to deliver services that are clinically sound. On a wider context, the need to do a better analysis and to apply management and fmancing methods has to be harnessed. The installation of quality assurance programmes to improve standards and use resource more effectively and at a lower cost should also be prioritized. As a whole, the overall challenge to Mongolia is how to use limited funds to the fullest by securing the ideals essential to health care delivery, ensuring targeted spending of health care fmancing funds and improving performance and management through the proper use of information to aid in policy-making.
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Philippines (presented by Ms Maylene Beltran, Chief Health Programme Officer, Health Policy Development and Planning Bureau, Department of Health) • The Philippine health sector continues to face many challenges, among these are: increasing economic difficulties that threaten the gains in health status; the double burden of disease as infectious disease as well as degenerative diseases continue to escalate; fragmentation of the health referral system brought about by the decentralization of health services; and poor fmancing of health care services. Issues in health care fmancing in the Philippines include: • • • How to increase the total resources for health; How to increase allocation for preventive and promotive services; How to increase production of goods and services out of existing resources; and How to reduce gaps in terms of access and utilization of services.
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A response to all of these issues and challenges is the implementation of the Health Sector Reform initiative which aims to improve the health status of the people through improved health sector performance along five pillars: health insurance; public health programmes; fiscal autonomy of hospitals; health regulation; and local health systems development.
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Samoa (presented by Ms Frances Brebner, Director, Department ofHealth Planning, Information and Research) • Health expenditure as a percentage ofGDP in Samoa is 6.6%. The majority of funds come from the public sector and the hospitals are receiving the highest allocation. Concomitantly, curative care receives the highest share of expenditures in the health sector. Through the recently conducted NHA exercise, a clear and comprehensive framework to introduce reform in financing, allocation, health systems and services was formalized. Currently, government spending on health is relatively high and it may not be possible to increase government resource allocation further. Many questions and issues still need to be addressed in relation to the financing ofhealth services in Samoa. The following are some of the questions: • What is the most appropriate mechanism to finance health services in the light of diminishing capacity of government to fund health care? What are the roles of the different key players in the financing of health services- government, private sector and individual households? Who should manage the funds? What is the proper allocation of resources in order to be truly responsive to the needs of the country?
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VietNam (presented by Dr Tran Van Tien, Acting Vice Director, VietNam Social Security) • Health care financing is a relatively new term for many legislators and policy-makers in VietNam. Differing opinions and viewpoints continue to pervade and even existing decrees or regulations are conflicting. There is a low level of government spending for health, which is estimated to be less than 1%, and there is an increasing private spending through various forms of out-of-pocket payments. .
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The low salary of health care personnel has contributed to the preponderance of informal payments to health care providers. Only a small percentage of the poor are covered by the free health cards thus leaving many vulnerable. Social health insurance has been implemented since 1992 and the recent merger of the health insurance system and the pension system has led to many changes in health insurance policy and may serve as a deterrent to the health insurance system.
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Cross Cutting Issues and Challenges in Health Care Financing (HCF) among Member States
The following are some of the common issues and challenges on health care financing that were presented in different country presentations: • Out-of-pocket spending accounts for the biggest share in financing health services. Emphasis in Health Care Financing is still in the area of curative care.
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An emerging role that private sector plays in health care delivery and financing health services. Information provided by National Health Accounts (NHA) plays a significant role in the development, monitoring and evaluation of Health Care Financing. Currently NHA is in various stages of development among Member States.
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In some situations, discussions and plans towards health sector reform, particularly in the area of health care financing, have been going on for quite some time yet have been slow in transforming this into actual operations and implementation. Recognizing the crucial participation of all stakeholders, including informal sector groups and the beneficiary groups, in policy-making, planning, implementing and monitoring health care financing schemes.
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2.4
Presentations on National Health Accounts (NHA)
After the country presentations on the different issues and challenges confronted by the Western Pacific Region countries in the arena of health care financing, three resource speakers were invited to expound on how the NHA can be used as a policy tool and what are various challenges faced in institutionalizing the NHA.
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Dr Ravindra Rannan-Eliya, Associate Fellow, Health Policy Programme, Institute of Policy Studies, presented a brief description of the evolution ofNHA and its various policy uses. Among the most important policy uses ofhealth accounts are in the diagnosis of health care systems, the assessment of funding requirements and projection of health care costs. Moreover, health accounts are used as tools for assessing reforms or trends, benchmarking health system performance and assessing distributional issues. Various countries around the world are in different stages of implementation of their NHA. Some countries in the Western Pacific Region already have institutionalized NHA systems while others have already expressed an intention to make NHA permanent. As a whole, there are many lessons learned and best practices to be culled from the work of developing and institutionalizing NHA in different countries. Foremost among these are the following: • • • The process of developing and implementing NHA takes time. At the outset, it is important to ensure institutionalization ofNHA. It is necessary to develop institutional partnerships and to distinguish commissioning and technical roles. The use of routine data sources must be stressed and multiple year data estimates need to be done even from the beginning. It is not advisable to rely heavily on household survey data.
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Subsequently, Ms Frances Brebner and Ms Maylene Beltran of Samoa and the Philippines, respectively, shared some of their experiences on the use ofNHA. Even at its early stages of development, the NHA is a vital tool for health reform activities because it can be used as a powerful political tool for negotiation. It also helps to improve estimates and projections in various processes including resource planning and allocation. More importantly, the NHA can serve as a monitoring and evaluation tool in tracking policy and reform outcomes. It then becomes a reference for advocacy and public discussions. 2.5 Health Care Financing Theme 1: Revenue Collection
To better capture the three main areas of concern in health care financing and to create a springboard for working group discussions, resource persons were invited to set the tone and identify key concerns in the various arenas of financing. Three resource speakers gave presentations relating to options and possibilities of mobilizing financial resource for health care, taking into consideration issues of ensuring equity, looking into new opportunities in the field of health promotion fmancing and exploring ways by which public and private financing in health care can address poverty.
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Dr Stephen Fabricant, Consultant, presented the various goals that guide fmancing policy, the features and arenas of equity and how equity and fmancing policy relate to each other. He also identified four main modes of resource mobilization for health. These are: general taxation, earmarked taxes, pooling (social insurance) and cost-sharing. Each of these modalities has strengths and weaknesses in so far as how they would achieve equity. The challenge is how to strike a balance among the different modalities and how they can best be used to achieve an overall net effect of equity as they relate to health financing policy objectives. Subsequently an illustrative case was presented by Dr Shanlian Hu on how China has mobilized public financing as the most important method of covering financial risk for the poor in order to be able to improve access to health services in the poor areas. Through its Aid-the-Poor Programme, China's poor population has declined substantively. Several key lessons can be drawn from China's experience. The public and private sector play very important roles in health fmancing in developing countries. Government's role in health fmancing is to use its limited funds to ensure the delivery of public health programmes, foster rural health, promote maternal and child health, disease control, supervise health programmes and implement poverty reduction schemes. More importantly, there is a need for a strong commitment on the part of government towards poverty alleviation and increasing capital input for poverty reduction. A final consideration in the area of revenue collection is the aspect of opportunities that health promotion fmancing provides. Dr Susan Mercado, Acting Regional Adviser in Health Promotion, gave a brief update and input on the tight relationship of health promotion to health financing and the opportunities it presents. The Ottawa Charter of 1986 defines health promotion as "the process of enabling people to increase control over and improve health." Broadening health promotion financing arrangement options contributes to the overall goal of health fmancing. There have been several recent developments in the Western Pacific Region in relation to health promotion fmancing. In order to pursue broader health promotion fmancing options, it is necessary to link these to other components of health sector reforms. Changes in health promotion fmancing arrangements are inextricably linked to the way health promotion will be organized and delivered. Moreover, health promotion fmancing presents some issues and challenges that need to be further explored. These include: determining whether health promotion is a personal or public health cost; whether health promotion expenditures can be casted out separately from prevention; identifying the extent by which social security funds can be allocated for health promotion; and building the relevant political and economic environment that is favourable for using earmarked taxes for health promotion. These are just some of the relevant issues that need to be explored in relation to this very important component of health promotion fmancing. 2.6 Health Care Financing Theme 2: Pooling Financial Resources
For the second major area of discussion on health care fmancing, four resource speakers presented different dimensions and experiences relating to fund pooling.
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Dr Aviva Ron's presentation gave key concepts and features that relate to financial protection through mechanisms of risk shari.ng and fund pooling. Financial protection for health care is necessary for a variety of reasons. Among these are realities such as government's inability to provide all health care free of charge, health care costing far higher than other personal goods and services, the burden of health care may be too high for individuals and families, families have multiple needs and savings usually serve other needs and purposes. Risk sharing that occurs at various levels implies that defined partners have a joint responsibility for health care costs. This includes recognition that illness and subsequent costs are random events and are generally not predictable, that the financial burden of health care costs on households may have health implications in terms of spreading the risk of illness by those who delay and that higher health care costs are incurred due to delay in seeking care. Fund pooling mechanisms, on the other hand, include the determination of defmed contribution at a defined time for defined populations who thereby become entitled to defined benefits of the fund. A fair formula should be used to determine the amount of contributions for each insured unit. Also, the fund must be managed in such a way that it guarantees the use of the funds for benefits provision as well as administration and development of the fund both in the short and long term. However, financial protection through risk sharing and fund pooling are not the only components and aspects in social health insurance. Often, the "social" component is left out. Considerations for the political and legislative environment that will ensure solidarity, equity and social assistance to the vulnerable groups must be ensured. Also it must be stressed that the fund pooled for the provision of a package of health services is non-profit in nature. Furthermore, pre-paid contributions should be determined appropriately and this should be properly disseminated among members. Also, these funds must also be used for preventive care and the promotion ofhealth system development. More importantly, health insurance should be viewed and approached as part of a broader social security framework that encompasses all contingencies that need fmancial protection and risk sharing. Three country experiences were subsequently presented. Dr Sodov Sonin shared some of the key lessons that Mongolia has learned in its efforts to achieve universal coverage for health insurance. Lessons learned include the realization that extending coverage to include primary and preventive care potentially reduces costs of hospitalization. Also there is a need to constantly review access and availability of services for the poor. There is likewise a need to train staff to ensure proper administration of health insurance as well as better control and coordination with other areas of health policy. The need to develop guidelines and protocols has also been recognized as a means by which efficient use of funds is ensured. The poor may also need to be exempted from co-payment and the family should be the unit of membership in order that all members of the family are assured of coverage to the insurance scheme. Subsequently, experiences on community health insurance in the Philippines were presented by Dr Marife Yap, Associate Director, Health Unit, Ateneo Graduate School of Business. Efforts have been exerted to document and categorize the numerous community-
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based health schemes that have been in existence in the Philippines. These alternative health schemes have emerged due to increasing difficulty in accessing health services brought about by geographical factors, aggravated by the lack of health personnel and low government prioritization ofhealth in terms of funding and technical support. Thus, several models of health schemes have emerged. A United Nations Children's Fund (UNICEF)-sponsored study attempted to classify these schemes as follows: health insurance schemes; modified health insurance projects; income generating projects; integrated primary health care projects; and purely economic activities. This classification took into consideration the main reason and benefit that such scheme brings to Its members and beneficiaries. Another study also identified schemes that had features and components that are commonly identified with a health insurance scheme. This study was able to identify three categories, classified according to the main initiator and implementer of the scheme. The three main categories are: Local Government Unit-driven Model, Non-government/People's Organization-driven Model, and Cooperative-driven Model. Presently, there are active efforts on the part of the Philippine Health Insurance Corporation to recognize, defme and identify areas of interface between these community insurance schemes and the National Health Insurance Programme being implemented in the country in order to fully maximize the potential of these schemes as well as ensure its sustainability beyond their local areas of coverage. The fourth presentation for the theme on funds pooling was given by Mr Afsar Akal, Technical Officer, Health Insurance Specialist, WHO VietNam, who shared experiences of fund pooling in Australia and VietNam. In Australia, universal access to health care is through Medicare that is financed largely from general taxation revenue, including a Medicare levy that is based on an individual's income tax. Choices are presented to individual members through a substantial private sector involvement in delivery and fmancing. The issues that Australia faces in relation to health fmancing include crafting the appropriate response to the system's inability to respond to the needs of aborigines and their health needs. Government's inability to consider the needs of aborigines has led to poorer health conditions among this sector as compared to the non-aboriginal populations. Further to this, the system is also not able to appropriately respond to the needs of the chronically ill. · In the case of VietNam, an exercise in pooling funds is being implemented through a community-based health insurance pilot scheme that is receiving funds from various internal and external sources. There are several interesting areas of comparison that can be observed between the experience in health fmancing of a developed country with a longer history of pooling funds and implementing health insurance with a developing country that is at its infancy in relation to health insurance implementation. 2.7 Health Care Financing Theme 3: Purchasing Health Services
The third major theme, health care financing, addressed purchasing of health services from two perspectives: determining the kind of services to be purchased or the benefit .packag~ and mechanisms for health service provider payments. Five resource speakers were invited to shed light on these important topics.
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2.7.1
What to Buy
In order to get a better grasp of the areas for consideration in priority setting and purchasing, Dr Toshihiko Hasegawa, Director, Department of Health Care Policy, Japan, presented a framework to be considered in determining the appropriate set of health services to be purchased in a health care fmancing scheme. He cited four main functions of a health system: stewardship (oversight); service provision; fmancing; and resource generation. Different countries have structured their own health systems accordingly in order to be able to serve these key functions.
Thus, the determination of the appropriate package of health services to be delivered is done through a priority-setting process that is influenced by key stakeholders of the system. Setting priorities comes about due to limited resources and can be carried out through political processes or based on technical methodologies. There have been varying experiences from different countries on the use of these techniques in setting priorities. What is most important in the final analysis is that an essential package of health services can be determined that will be responsive to needs and demand, will be cost efficient and will benefit a huge portion of the target population. The second paper presented focused on the use of a model to guide decision-making in health care to achieve the most appropriate mix of services. The speaker, Ms Carol Beaver, Short-term Professional on Health Economics and Financing, Western Pacific Regional Office, notes that within countries, there is often diversity in the provision of health services. This diversity has a great impact on costs and the availability and distribution of resources that may in turn lead to some inefficiency in the provision of services and inequity in access to health care. In order for health care managers to make informed decisions, they should have access to easy to use and relatively cost-effective methods of getting the needed data and information. These can then be used to formulate and revise policy as well as to make purchasing decisions. Recent work in the United Kingdom, Australia and Pacific Island countries have used the Health Benefit Group/Healthcare Resource Group (HBG/HRG) classification model that allows for the linkage of information on needs, outputs, costs and outcomes. The framework that is being used by this model can provide a relatively cost-effective way of assisting buyers of health services to set priorities and to arrive at an appropriate mix of services across the care continuum. The Health Care Framework (HCF) based on the HBG/HRG classification is an information model that provides a structure that allows for identification and consideration of issues across the care continuum. The framework provides a sound foundation for exploring and modelling the impact of alternative planning and purchasing strategies. An example on the use of this framework was presented through a presentation of key fmding for a sixcountry study on diabetes expenditure.
- 19-
2. 7.2
How to pay
The three subsequent papers dealt with inputs on how to better understand mechanisms for paying health providers. Learning and insights from two countries' experience of paying for health services were also presented. Ms Karen Quigley, Instructor, Harvard University School of Public Health, gave an overview of the different payment mechanisms and incentives for health care providers. Payment systems for health providers exist to respond to various goals. Included among these goals are to provide access to needed services, to recognize and reward high quality care and the promotion of efficient production and distribution of health services. A wide variety of payment methods are used such as fee for service schemes (individual and aggregate services), global payment and patient based on capitation scheme. No payment method is perfect. Each scheme has its own strengths and weaknesses. The best approach varies depending on economic, social, political and institutional context. Experiences in many countries have also shown that payment systems evolve over time. Development of these schemes is incremental and tools, data and understanding of these schemes are likewise developed over time. Certain circumstances require a blending of methods in order to arrive at the optimal approach. Through blending of different methods, incentives of payment methods are aligned with the desired service provider behaviour and desired outcomes are achieved with lesser incremental costs. One mechanism used for purchasing of health services is contracting. Dr Aye Aye Thwin, Health Financing Adviser, WHO Cambodia, presented Cambodia's experience with contracting health services. Contracting is the process of granting responsibility and authority to an agency to manage health services for a particular catchment area. The contracting experiment in Cambodia hoped to be able to give NGOs the responsibility and the capacity to deliver health services at the district level. Contracting of public health services was done due to limited capacity of existing public sector services and systems, difficult to reach populations and the need to accelerate efficiency and effectiveness. Two variants of contracting were piloted in Cambodia - contracting out and contracting in. Contracting out is when the contractor has full responsibility and management authority to deliver district health services. Thus, the contractor directly employs and pays health staff as well as procures all supplies and pays for operating costs through contract funds. Contracting in, on the other hand, means that a contractor is hired in to manage district health interventions. Health staff continue as civil service employees and all operating costs, salaries and costs to purchase drugs come from government. Presently, contracting in/out of health services in Cambodia has resulted in high utilization of essential health services especially in comparison with baseline, enhanced efficiency in service delivery, significant improvements in service quality and improved management practices within the public sector. On the other hand, among the problems encountered were poor access to allocated funds from government, confusion of roles, delays
-20-
in procurement of equipment and filling staff vacancies, difficulty in getting support from Ministry ofHealth technical departments and difficulty in relationship with some health districts. The Cambodian experience of contracting health services indicates that this mechanism of purchasing services may have some uses in countries with similar circumstances. There is, however, further work that needs to be done in relation to the documentation of best practices, the evaluation and scaling-up of cost-effective service delivery models, the institutionalization and transfer of good management practices into public sector and the development of strategic roles for NGOs. The final presentation on purchasing dealt with official, unofficial and informal fees for health care. Dr James Killingworth, Technical Officer, WHO China, in his presentation stressed the need to distinguish official, unofficial and informal fees as these exist in many health systems in some countries. Unofficial fees necessarily refer to an authoritative mechanism of fee setting: some fees are set by authorities and some are not. It has been observed that unofficial and informal fees create health system irrationality. These also raise the probability that health service access will be reduced for the poor, health service revenue will be diverted from stated system uses, "inefficiencies" will emerge and enlarge while system effectiveness decreases and perverse practice incentives will increase. Cases from three countries were used as examples to better understand this phenomenon. Some points raised in relation to unofficial fees are major problems of access and quality that may be associated with fees of any sort under right conditions and institutional and social history does influence the operation of official and outside fees in a health system. Thus from these initial points of analysis raised, it indicates that health system goals are indeed affected by "fees" and that unofficial and informal fees needs to be analyzed further to better understand its impact in a health system. 2.8 Summary of Key Issues Raised (from paper presentations)
After all the papers presented, a review and summary of the past two days of the third TAG meeting was made by the rapporteur. The following were the key points presented: Theme 1: Revenue Collection a. Equity has many dimensions. Considerations for ensuring equity are highly dependent on what society wants (i.e. financing goals -universal coverage? equitable benefits?). b. The challenges to HCF in ensuring that equity encompasses areas related to resource mobilization - general taxation, earmarked taxation, pooling and cost-sharing. c. As a whole, the main issue is whether or not equity considerations among different sources of resources can be balanced.
-21 -
d. Financing health services entails defming the roles and areas of interface between the private and public sector. It is important that governments seriously look at how goals are fully met in partnership with the private sector. e. Health promotion is a fundamental component to be considered in discussing, planning and implementing HCF. In the long run, investments in this area will contribute significantly to the sustainability of fmancing schemes. f. The following are some dimensions in Health Promotion in relation to HCF that need to be explored: - Health promotion: personal or public health; - Allocation for health promotion; - Political and economic environment necessary to pursue health promotion; and - Health Promotion and National Health Accounts. Theme 2: Pooling Financial Resources a. Fund pooling and risk sharing are only some of the other areas that need to be considered in discussions on HCF. Equally important is the policy and legislative environment where these mechanisms exist. b. Pooling of funds should be more family-based rather than individualbased. c. It is not sufficient to simply determine methods of pooling the fund or sharing the risk, a systemic view in looking at health development is critical and necessary. d. Health insurance should be viewed as part of a broader social security framework. e. Community-based health insurance efforts, although limited in success, should be considered opportunities and areas for people to understand and appreciate insurance concepts, issues and mechanism better. In so doing, it becomes an interim step towards eventual interface into a national health insurance scheme. Theme 3: Purchasing Health Services a. Models used in priority setting for health services have to be appropriate and applicable to specific settings and situations. Factors such as political processes and technical methodologies should be considered in determining priorities.
-22-
· b. The Health Care Framework is a new way of categorizing health care services to inform resource allocation and purchasing decisions. c. This new framework considers the use of HBG and HRG to better understand cost of disease across the continuum of care. d. Various mechanisms of provider payments have their own strengths and weaknesses. Several factors and components are to be considered in determining the best paylnent mechanism. Often, blending of methods maybe the optimal approach to provider payment.
3. OUTPUT OF WORKING GROUPS
Following the presentation of the review and summary of proceedings for the past two days, the working group session was introduced. Participants were grouped around the three main themes that were to be discussed in the small groups. Each of the three working groups was asked to discuss the theme assigned to them in relation to the following: • • Key issues and challenges presented by the theme to be discussed. Strategies that would help to address these issues and challenges at various levels. Possible areas ofNHA data related to the theme. The role of the Western Pacific Regional Office in collaboration with other partners, in implementing these strategies. Specific recommendations for the Western Pacific Regional Office to strengthen health care financing activities at the regional and country levels.
• •
•
The list of participants for each working group is attached as Annex 4 of this report.
3.1
Working Group 1 Output: Revenue Collection ISSUES AND CHALLENGES STRATEGIES USEOFNHA ROLEOFWPRO SPECIFIC RECOMMENDATIONS TOWPRO
The Western Pacific Region is diverse - wide range of political, economic, social conditions, different approaches to financing needs. These affect all of the following issues
Categorization, look at common factors within groupings
• •
Useful for comparing sources and uses Disaggregate by equity socioeconomic and other indicators Focus on essentials where change is most needed and/or rapid
•
Technical assistance reflecting difference between groups of countries Forum for policy discussions between diverse audiences
•
•
Develop and use typology of countries (low/medium income; transitional/islands ) as basis for analysis and device Support country situation analyses for resource mobilization Organize discussions with diverse groups on resource mobilization Support development of technical capacity where weak Regional database Develop practical recommendations on implementing target (e.g. exemptions
•
•
•
• Out-of-pocket health expenditures are very high and inequitable in many countries, resulting in a significant barrier to access
•
Reduce out of pocket spending by increasing prepayment through tax-based systems or social insurance Make targeted subsidies work better
•
Use to monitor Contributory research in health care fmancing
• •
Advocacy for propoor HCF policies Case studies, dissemination
• •
•
•
ISSUES AND CHALLENGES
STRATEGIES
USEOFNHA
ROLEOFWPRO
SPECIFIC RECOMMENDATIONS TOWPRO
(e.g. exemptions, improve quality of public services, reduce subsidy to rich) Tax funding basis for health is very low.
• •
Increase tax general revenue allocation for health Earmarked taxes improve efficiency
•
Use to monitor
•
•
In low growth, low income countries' taxation is not a viable short-term fmancing mode How to increase formal sector economy contribution Improve progressiveness of taxation Health is too low as a priority
Advocacy in other ministries, political leadership, mass media Review earmarked "sin taxes" for health
•
Support political leadership in Ministry of Health -skills, information Support national health financing forum with media and with other United Nations agencies.
•
•
•
• •
Large and increasing informal sector
•
Improve productivity and efficiency of public sector Increase government support for developing appropriate SHI and CBI Strengthen legislative framework for SHI
•
Use to monitor equity of financing efficiency
•
• •
Inadequate resources going to pooling Social Health Insurance (SHI) is restricted to formal sector and can be regressive
Technical Assistance, networking/ partnership·for SHI Policy discussions WHO Headquarters, International Labour Organisation, Asian Development Bank on CBI and micro
•
Document best practices, lessons inCBI Strengthen development of SHI, including legislation Promoting, mobilizing technical expertise
•
•
•
•
•
ISSUES AND CHALLENGES
STRATEGIES
USEOFNHA
ROLEOFWPRO
SPECIFIC RECOMMENDATIONS TOWPRO inter-regional networking
•
Weak, organized community-based financing, low government and popular support for Community Based Insurance (CBI) Weak capacity and political will to ensure equity
and CBI (legislative or regulatory)
credit
•
Legal framework for private sector regulation Linkages with microcredit schemes
•
•
•
Translate Headquarters policy/global regional recommendations to country recommendations
• •
Study role of private insurance Develop evidence on microfmancing and reinsurance and health Database development: political cycle, health legislation Coordination of technical units to promote crosscutting pro-poor focus
•
Poorest countries will continue to rely on external assistance forHCF
•
Document uses of private savings and potential for health fmancing/ pooling Advocate for external assistance and better allocation of use and equitable use
•
Monitoring
• •
Advocacy Ensure equitable use of external funding Pro-poor
•
•
Other sources
•
•
3.2
Working Group 2 Output: Pooling Financial Resources STRATEGIES COLLABORATING PARTNERS SPECIFIC RECOMMENDATIONS FOR WHO!WPRO
ISSUES AND CHALLENGES
PRE POOLING
•
• • •
Getting consideration for alternative health financing options among policy makers Getting common understanding of these options Getting public understanding of these options and their roles, social responsibility for social protection Defming.the statutory roles of Ministry of Health and social insurance agencies of Ministry of Labour and Welfare and other agencies in charge of social protection Inadequate technical and managerial capacity A policy document preparation of draft documents Under which institutional framework you set up social health insurance (broad social security approach or separate health institution?)
Doing feasibility studies that carefully identify "stakeholders and enabling agencies" Creating awareness by way of seminars, workshops for decision makers (the concept of risk sharing and pooling) Intensive training to a critical mass of national people Using "people of influence", figureheads to convey message to the public, using all media Review all existing legislations and recommend amendments Mobilize appropriate levels of expertise in relevant fields to develop policy documents and legislative tools
•
Relevant government agencies, social security agencies Legislative bodies Relevant non-government agencies Health provider associations Employer associations and unwns National institutes ofhealth and welfare and economic institutes Development partners, United Nations Agencies, including institutions, donors
•
Assist countries to develop master plan on health financing Assist the training of senior officials and assist: "training of trainers" Assist in mobilizing expertise for development of policy tools Facilitate sensitization of stakeholders at all levels and consensus building Assist reviews options for institutional frameworks Assist the design of studies Assist experience exchange between members' governments Assist policy development and time frame for reaching universal coverage
•
• • • • • •
• •
• •
• •
•
N 0\
• • •
•
• • •
•
..
ISSUES AND CHALLENGES
STRATEGIES
COLLABORATING PARTNERS
SPECIFIC RECOMMENDATIONS FOR WHOIWPRO
POOLING
• • • •
Appoint the bodies to steer the process Review existing social security structures Studies of population sectors Studies on household expenditure on health Studies on cost and utilization of health services labour factors such as existing social security contributions Stakeholder consultations for consensus building Review civil servant salaries and fringe benefits Decision on single or pluralistic, social health insurance schemes Developing policies for establishing, merging social health insurance schemes to allow portability of entitlements + universal coverage
• •
•
Optimum level of pooling (family, community, labour sector, national across schemes) to reach universal coverage Appropriate policies for commercial health insurance Optimum level and type of contributions Appropriate policy for those that can not contribute (social assistance) Who would be the contributing partners and what would be their relative share of contributions Achieving acceptance (civil servants) Guarantees for cross subsidization Assuring compliance by all partners Conflicting existing legislation
Assist setting up pilot schemes and evaluating pilot and existing schemes Assist development of implementation projects within the master plan framework
•
• • •
•
• •
N -..l
•
• •
• • •
..
3.3
Working Group 3 Output: Purchasing ofHealth Services
OPENING PREAMBLE 1. The group discussed the definition of"purchasing" and the difference from "budgeting" and or "payment". Purchasing is not reactive payment to provider services but active and strategic activity of purchaser. For purchasing, five elements are identified: 1) authority; 2) choices; 3) awareness; 4) capacity/information; and 5) economic transaction. The group set the scope of discussion mainly in purchasing with public fund including tax, social insurance fund and co-payment for public and private provider. But out of pocket payment and purchasing between private sector agencies was decided to be an important issue and would be discussed under "general Government role" or "stewardship function" such as protection of consumer, information dissemination, etc. Purchasing is a complex issue involved in many different levels and aspects. Further research and survey is required to understand and to develop sound recommendations for the implementation of Member States. Particularly for the level of impl~mentation, context of the country is very important. Model and operation should be tailored to the national context. WHO has a special partnership role different from other international agencies to assist and guide the Member States for all different level of purchasing. Issues and Challenges Lack of Awareness of what purchasing actually involves or requires not only within Ministry of Health but in the larger government and even community. Strategies • Changing of mindset and/or philosophydissemination on concepts, strategies and experience • Provision of skills to analyze, conceptualize and articulate the needs for purchasing, its role in health sector reform etc. Collaborative Partner's Role Community groups Recommendation for WHO • Help articulate the role of purchasing • Dissemination at national and regional level of conceptual issues, strategic approaches, experiences and best practices in purchasing • Research, analysis and identification of key issues of new public sector manage.ment relevant to purchasing at the national level. N 00
2.
3.
Issues and Challenges
Strategies
Collaborative Partner's Role
Recommendation for WHO
Enabling public sector /Ministry of Health to develop strategic policy decision-making with regard to Purchasing • Purchasing practices not in line with overall government strategic plan • Assessing.proposals and handling interactions with other gov:emment agencies and donors • Ministry of Health does not have the final decision-making power in many health sector reform activities including purchasing. • Ministry of Health may not be the initiating agency Empowering Ministry of Health and other public sector agencies in implementing purchasing models and other related changes to current practice
• Strengthening capabilities of ministries through provision of knowledge and skills • Empowering Ministry of Health in a more knowledgeable position when policies are affected from a higher level so that the Ministry of Health can respond appropriately
• Research, analysis and workshops • Institutional/political/stakeholder mapping • Enhancing skills • Demonstration of projects • Compilation/analysis of best practice from the region and globally. • Partnerships with other donor agencies at the national level to achieve capacity building • WHO to advice Ministry of Health and help in the analysis of understanding the implications of changes in policy to the Ministry of Health and how the Ministry of Health can interact/negotiate with other government agencies to the interest of the health care system
In major reforms, contributing funds and other resources, and specific technical skills Joint development of implementation plans at the national level. Contributing information
• Helping countries with analysis of situation, • Assistance with conceptual issues • Training for Ministry of Health /public agency and providers • Analysis, compilation and dissemination of experiences and best practices in implementation and translation into
• Building capacity of Ministry of Health to discuss with other partner agencies and central government agencies • Advocacy and articulation at the higher level of government on the need for transparency and accountability particularly in relation to Ministry of Health's role of stewardship and governance Weakness of information systems Decision-making not evidence-based even with available information Set-up and/or strengthen information systems Training on policydecision-making tools to link data to addressing needs Technical assistance in developing requisite skills
Training
0
w
- 31 _;
4. CONCLUSION AND RECOMMENDATIONS
The output of discussions from the three working groups was substantive and informative. Most of the issues and challenges that were presented by the different working groups were a more detailed articulation of the cross-cutting issues and themes that were presented in the earlier paper presentations. Many strategies were proposed by the working groups to respond to the various issues and challenges for each of the key themes on health care financing. As a way of summarizing these, the strategies that were identified by the three working groups included the following: • Different stakeholders in the health care delivery system need to -undergo a shift in paradigm and mindset by which they define health care financing and its strategies. Review of key legislation and policy formulation on establishing and/or merging appropriate social health insurance schemes. Linking and networking among key government line agencies as wells as between the public and private sectors that impact on health care financing. Capacity-building and skills enhancement on health care financing for stakeholders in the pubic sector (Ministries ofHealth, Ministries of Labour and Welfare) and the private sector (organizations, communities and individuals). Conduct of necessary research, including studies on population sectors, household expenditures on health, cost and utilization of health services and documentation of best practices of pilot schemes to generate lessons that will enable the formulation of a general framework towards arriving at an appropriate health care financing scheme for the different countries. Advocacy and awareness raising on health care financing - issues, challenges and strategies that will enable an informed decision-making process among key decision makers and beneficiaries.
•
•
•
•
•
•
Stakeholder consultation for consensus building.
An important challenge raised at the outset, which continued to re-surface for the duration of the TAG meeting, was the realization that health care financing is not the sole responsibility and concern of the Ministries of Health. It is a cross-cutting theme that affects many other branches of government, including the executive and legislative branches. An enabling environment that will pursue and institutionalize health care financing on a larger scale requires multi-stakeholder involvement and participation not only of the public sector but also of different players within the private sector, especially the beneficiaries and communities. A process of consensus-building is also recommended in order to arrive at a more sustainable scheme. In addition to this, sharing of resources, experiences and learning among countries also needs to be fostered in order to better appropriate the identified strategies so that these become responsive to the setting and context of countries. All of the working groups also presented specific recommendations that the Western Pacific Regional Office could do to ensure that health care financing as a priority concern will be addressed by the different Member States to ensure a more equitable access to health care for all.
. -32The recommendations that WHO could act on can be clustered into the following general areas: (1) policy studies, research and documentation, including pilot implementation of schemes;; (2) capacity-building; and (3) networking and partnership building, including advocacy. Some examples of recommendations that were presented as areas that WHO could do in health financing are presented in the table below. Area Policy Studies, Research and Documentation, including pilot implementation of schemes Examples ofRecommendations Theme 1: Revenue Collection • Develop and use typology of countries as basis for analysis and device • Regional databases • Develop practical reco~endations on · implementing targets • Document best practices lessons in Community Based Insurance • Study the role of private insurance Theme 2: Pooling Financial Resources • Assist review options for institutional frameworks • Assist the design of studies • Assist policy development and time frame for reaching universal coverage • Assist setting up pilot schemes and evaluating pilot and existing schemes Theme 3: Purchasing ofHealth Services • Help articulate the role of purchasing • Research, analysis and identification of key issues of new public sector management relevant to purchasing at the national level • Institutional/political/stakeholder mapping • Demonstration of projects • Compilation/analysis of best practice from the region and globally Capacity-building Theme 1: Revenue Collection • Support development of technical
- 33capacity where weak • Support political leadership in the Ministry of Health - skills, information • Strengthen development of SHI : including legislation Theme 2: Pooling Financial Resources • Assist the training of senior officials and assist " training of trainers" Theme 3: Purchasing ofHealth Services • Enhancing skills • Training for Ministry of Health/public agency and providers • Building capacity of Ministry ofHealth to discuss with other partner agencies and central government agencies • Technical assistance in developing requisite skills
Networking and Partnership Building, including advocacy
Theme 1: Revenue Collection • Organize discussions with diverse groups on resource mobilization • Support national health fmancing forum with media and with other UN agencies • Promoting, mobilizing technical expertise inter-regional networking • Coordination of technical units to promote cross-cutting, pro-poor focus Theme 2: Pooling Financial Resources • Assist in mobilizing expertise for development of policy tools • Facilitate sensitization of stakeholders at all levels and consensus building • Assist experience exchange between members' governments
-34Theme 3: Purchasing ofHealth Services • Dissemination at national and regional level of conceptual issues, strategic approaches, experiences and best practices in purchasing • Partnerships with donor agencies at the national level to achieve capacity building • WHO to advise the Ministry of Health and help in the analysis of understanding the implications of changes in policy to the Ministry of Health and how the Ministry of Health can mteract/negotiate with other government agencies to the interest of the healthcare system • Advocacy and articulation at the higher level of government on the need for transparency and accountability particularly in relation to the Ministry of Health's role of stewardship and governance
At the end of the three-day TAG meeting, many of the participants recognized that health care financing is truly a core component of health systems and health sector reform in the Region. Also there was the realization that this issue includes many aspects and dimensions that are distinct as well as interconnected and cross-cutting. Thus the framework that will be developed should take all of these ideas into consideration. Furthermore, the diversity and distinctiveness of each Member State in the Region requires that a careful, smart and strategic approach be taken in developing this framework. Much as there is the desire to produce one generic framework that will serve as guide for all Member States, there must be sufficient room for flexibility and adaptation. All these require and highlight the value of close collaboration, regular networking and exchange of experiences and rigor in documenting and identifying significant learning. An important next step therefore after this fruitful and substantive TAG meeting is to re-visit the recommendations presented, review existing studies and pilot cases and begin the work of consulting, consolidating and drafting the Regional Framework on Health Care Financing for the Western Pacific Regional Office. During the closing ceremonies of the meeting, the output of the working groups was presented to the Regional Director. He in turn expressed his deep appreciation, gratitude and admiration for the conscientious effort of the participants and reiterated the enormity of the challenge that health care financing brings. Dr Omi also stressed once more the value of crafting on-the-ground, practical and realistic recommendations that can be implemented. The Third TAG Meeting was then formally adjourned by the Chairperson after expressing his thanks to all participants of the meeting.
ANNEX 1
WORL D
HEALT H
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONA L DU PACIFIQUE OCCIDEN TAL
THIRD HEALTH SECTOR DEVELO PMENT TECHNI CAL ADVISORY GROUP MEETIN G: HEALTH CARE FINANCING IN THE WESTER N PACIFIC REGION Manila, Philippines 17-19 February 2003
WPR/1 CP/HRF/6.4/001/HCF(1 )/2003/IB/2 24 February 2003
ENGLISH ONLY
INFORM ATION BULLET IN NO. 2 PROVISI ONAL LIST OF MEMBER S, TEMPOR ARY ADVISERS, RESOUR CE PERSONS, CONSULTANT, REPRESENTATIVES/OBSERVERS AND SECRET ARIAT 1. MEMBER S
Dr Toshihiko Hasegawa Director Department of Policy Sciences National Institute of Public Health 2-3-6, Minami" Wako-shi Saitama 351-0104, Japan Tel/Fax. : +81-48-468-7983 Email : hasegawa@niph.go.jp Dr Phua Kai Hong Associate Professor and Head Health Services Research Department of Community, Occupational and Family Medicine National University of Singapore Md316,M edica1Dr ive 117597 Singapore Tel. : +65 6874 4988 Fax +65 6779 1489 Email : cofpkh@nus.edu.sg Dr Tran Van Tien Bao hiem xa hoi VietNam 7 Trang Thi, Roan Kiem HaNoi, VietNam Tel. : +84 4 936 1376 Mobile: +84 9 0345 4155 Fax : +84 4 934 4169 Email : vantien@hn.vnn.vn
WPRIICP/HRF/6.4/00 1/HCF(l )/2003/IB/2 page 2
Professor Tak:usei Umenai International University of Health and Welfare 2600-1 Kitakanemaru, Otawara City Tochigi Prefecture 324-8501 Japan Tel./Fax : +81-287-24-3637 Email : umenai@iuhw.ac.jp
2. TEMPORARY ADVISERS
Ms Maylene M. Beltran Chief Health Program Officer Health Policy Development and Planning Bureau Department of Health San Lazaro Compound Sta. Cruz, Manila Philippines Tel. : +63 2 711 5377 Ms Frances Brebner Director Department of Health Planning, Information and Research Private Mail Bag Apia, Samoa Tel. +685 21 212 Fax +685 24 496 Email brebner@heal th. gov. ws Dr Hu Shanlian Professor Training Center for Health Management School of Public Health, Fudan University 138 Yi Xue Yuan Road Shanghai 200032 People's Republic of China Tel. +86 21 6416 9550 Fax +8621 64161411 Email slhu@fudan.ac.cn hushan Iian@hotmail.com Dr Susan P. Mercado Makati Center for Patient Education Inc. 314 Medical Towers Makati 103 Rufino Street Legaspi Village Makati City, Philippines Telefax : 892 8578 894 5876
WPR/ICPIHRF /6.4/00 1/HCF( 1)/2003/IB/2 page 3 Mr Kyung-Tae Moon Deputy Minister for Planning and Management Ministry of Health and Welfare 1 Joogang-Dong, Kwacheon City Kyunggi-Do, 427-721 Republic of Korea Tel. +82 2 504 7720 Fax +82 2 503 5393 Email ktmoon@mohw.go.kr
Ms Karen M. Quigley Instructor Harvard University School of Public Health 43 Trernlett Street Dorchester, Massachusetts 02124 United States of America Tel. +617 265 4844 Fax +617 436 4320 Email kquigley@bu.edu. kmquigley@yahoo.com Dr Rozita Halina Tun Hussein Project Consultant Malaysia National Health Accounts Project Information and Documentation Systems Unit Planning and Development Department Ministry of Health Leve110, PERKIM Building, Jalan Ipoh 51200 Kuala Lumpur Malaysia Tel. +603 4045 7342 Fax +603 4045 7191 Email drozita@pd.jaring.my Mr Luke Rokovada Permanent Secretary for Health Ministry of Health Suva, Fiji Tel. +679 330 6177 Fax +679 330 6163 · Email lrokovada@health.gov.fj Lrokovada20@hotmail.com
Dr Sodov Sonin Executive Director Health Sector Development Programme Ministry of Health Street-2, Ulaanbaatar 48 Mongolia Telefax +976 11 321 755 Email hsrlp@magicnet.mn
WPR/ICP/HRF/6.4/001/HCF(l)/2003/IB/2 page4 3. RESOURCE PERSONS
Dr Stephen Fabricant Independent Consultant 2026 Ashland Mine Road Ashland, Oregon 97520 United States of America Tel. + 1 541 488 5427 +14138124174 Fax Email Sfab43@cs.com Dr Ravindra Rannan-Eliya Associate Fellow Health Policy Programme Institute of Policy Studies 99, St. Michael's Road, Colombo 3 Sri Lanka Tel. +94 1 431 368 Fax +94 1 431 395 Email ravi@ips.lk Dr Aviva Ron 5 Mordechai Our Street (Apt. 51) Ramat Poleg Netanya 42200 Israel Fax +972 9 885 5656 Email ronaviva@bezeqint.net
4. CONSULTANT
Dr Maria Eufemia C. Yap Associate Director Master of Health Services Administration Program Ateneo Graduate School of Business Rockwell Center, Makati City 1200 Philippines +63 2 899 7691 ext. 2211 Tel. Email : mcyap@nsclub.net 5. REPRESENTATIVES/OBSERVERS ASIAN DEVELOPMENT BANK
Dr Jacques Jeugmans Sr. Social Sectors Specialist Social Sectors Division Southeast Asia Department Asian Development Bank Pasig City, Metro Manila Fax : 636- 2408 or 636- 2444
WPR/ICPIHRF/6.4 /00 1/HCF(1 )/2003/IB/2 page 5 INTERNATIONA L LABOR ORGANIZATION
Ms Sylvia C. Fulgencio Senior Programme Assistant for Social Protection International Labour Organization Manila Office NEDA sa Makati Bldg. 106 Amorsolo St., Legaspi Village Makati City, Philippines Tel. (+632) 819 3614 Fax +632) 812 6143 Email fulgencio@ilomnl.org.ph
Dr Anna Lucila Asanza National Project Coordinator ILO/STEP Project on Extending Social Protection through Micro-health insurance schemes in the Informal Sector International Labour Organization Manila Office NEDA sa Makati Bldg. 106 Amorsolo St., Legaspi Village Makati City, Philippines Tel. (+632) 815-2354 or 819-3614 Fax (+632) 812 6143 Email asanza@ilomnl.org.ph
ASIA PACIFIC HEALTH ECONOMICS NETWORK (APHEN)
Dr Kaemthong Indaratna APHEN Co-ordinator WHO Collaborating Centre for Health Economics Chulalongkorn University Bangkok, Thailand Tel +66-2-2186243 Fax : +66-2-2513967 Email: Kaemthong.I@chula.ac.th
TOHO UNIVERSITY.SC HOOL OF MEDICINE
Dr Tomonori Hasegawa Associate Professor Department of Public Health Toho University School of Medicine Tokyo 143 8540 Japan Tel. 813 3762 4151 ext 2413 Fax 813 5493 5417 Email tommie@med. toho-u. ac.jp
WPR/ICPIHRF/6.4/001/HCF(1)/2003/IB/2 page 6
6. SECRETARIAT WHO/WPRO Dr Soe Nyunt-U Acting Director Health Sector Development WHO Regional Office for the Western Pacific Manila Philippines +63 2 528 9951 Tel. Fax +63 2 526 0279/526 0362/521 1036 Email nyuntus@wpro.who.int
Dr Edward Brian Doberstyn Director Combating Communicable Diseases WHO Regional Office for the Western Pacific Manila Philippines Tel. +63 2 528 9701 Fax +63 2 526 0279/526 0362/521 1036 Email doberstyne@wpro.who.int Dr Linda Milan* Director Building Healthy Communities and Populations WHO Regional Office for the Western Pacific Manila Philippines Tel. +63 2 528 9981 Fax +63 2 526 0279/526 0362/521 1036 Email milanl@wpro. who .int Mr Dorj suren Bayarsaikhan Technical Officer Health Care Financing WHO Regional Office for the Western Pacific Manila Philippines Tel. +63 2 528 9808 Fax +63 2 526 0279/526 0362/521 1036 Email bayarsaikhand@wpro.who.int
"unable to attend - on duty travel
WPRIICP/HRF/6.4/00 1/HCF(1 )/2003/IB/2 page 7 Ms Anjana Bhushan Short-term Professional in Health Care Financing (Poverty and Gender) WHO Regional Office for the Western Pacific Manila Philippines Tel. +63 2 528 9814 Fax +63 2 526 0279/526 0362/521 1036 Email bhushana@wpro.who.int Ms Carol Beaver Short-term Professional in Health Care Financing (Health Economics and Financing) WHO Regional Office for the Western Pacific Manila Philippines Tel +63 2 528 9848 Fax +63 2 526 0279/526 0362/521 1036 Email beaverc@wpro.who.int Dr Aye Aye Thwin Health Financing Adviser Office of the WHO Representative Phnom Penh, Cambodia Tel. +855 23 216610 Fax +855 23 216211 Email thwina@cam.wpro.who.int Professor James Killingsworth Technical Officer Country Advisor-Health System Development and Finance Office of the WHO Representative Beijing People's Republic of China Tel. +8610 6532 7189 Fax +8610 6532 2359 Email killingsworthj @chn.wpro. who.int Mr Yang Hongwei Programme Assistant Office of the WHO Representative Beijing People's Republic of China Tel. +861 0 6532 7189 Fax +8610 6532 2359 E-mail: YangHW@chn.wpro.who.int
WPRIICP/HRF/6.4/00l!HCF(1)/2003/IB/2 page 8 Mr Afsar Akal Technical Officer Health Insurance Specialist Office of the WHO Representative HaNoi VietNam (844) 943-3734 Tel. (844) 943-3740 Fax E-mail : Aka!A@vtn.wpro.who.int
Ms Nguyen Thi Kim Phuong Programme Coordinator Office of the WHO Representative HaNoi, VietNam : (844) 943-3734 Tel. : (844) 943-3740 Fax E-mail : J?h~1ong@vtn.wpro.who.int
WHO/SEARO
Dr Than Sein Director Evidence and Information Policy WHO Regional Office for South East Asia New Delhi - 110 002, India (91) 11-337 0804 Tel. (91) 11-337 9507 Fax E-mail : THANSEIN@whosea.org
Mr Javed A. Chowdhury STP/HSP WHO Regional Office for South East Asia New Delhi- 110 002, India (91) 11-337 0804 Tel. : (91) 11-337 9507 Fax
WHO/Headquarters
,
Dr Eugenio Villar Coordinator a.i., Poverty and Health Financing Department of Health Financing and Stewardship WHO Headquarters Geneva, Switzerland (4122) 791-2563 Tel. (4199) 791-4809 Fax Email : villare@who.int
ANNEX 2
WOR LD
HEAL TH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDE NTAL
TIDRD HEALT H SECTO R DEVEL OPMEN T TECHN ICAL ADVISORY GROUP MEETIN G: HEALT H CARE FINANC ING IN THE WESTE RN PACIFI C REGION Manila, Philippi nes 17-19 Februar y 2003
WPRJICPIHRF/6.4/001/HCF(1)/2003.1 5 Februar y 2003
ENGLIS H ONLY
PROVIS IONAL AGENDA
1. 2. 3. 4. 5.
Opening ceremony Overall health situation in the Western Pacific Region ~egional
overview on health care financing
Country presentations: Health care financing issues and challenges Presentations on National Health Accounts (NHA)• • • NHA as a policy tool: Guide for NHA development NHA development: Challenges and lessons from Samoa Use ofNHA in health policy formulation
Theme 1: Revenue collection 6. Presentations on Theme 1: Revenue collection • • • Mobilizing financial resources for health care: Ensuring equity Public and private financing in health care: Addressing poverty New opportunities for health promotion fmancing
.. ./
WPRIICPIHRF/6.4/001/HCF(1)/2003.1 page 2
' Theme 2: Pooling Financial Resources 7. Presentations on Theme 2: Pooling financial resources • • • • Financial protection through risk-sharing and fund pooling mechanisms Achieving universal coverage: Lessons learnt Community health insurance in the Philippines Fund pooling: The Australian experience
Theme 3: Purchasing health services-. What to buy and How to pay 8. Presentations on Theme 3- What to buy • • Health policy: Priority setting and purchasing Health care decision-making: Achieving an appropriate mix of services
9.
Presentations on Theme 3- How to pay • • • Payment mechanisms for health care providers and created incentives Contracting health services in Cambodia Formal and informal fees for health care
10. 11. 12.
Review and summary of the last two days and introduction to working groups Plenary session: Report of working groups and discussion Closing ceremony
ANNEX 3
WORL D
HEALT H
ORGANIZATION
ORGANISATION MONDJALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDEN TAL
THIRD HEALTH SECTOR DEVELO PMENT TECHNI CAL ADVISO RY GROUP MEETIN G: HEALTH CARE FINANC ING IN THE WESTER N PACIFIC REGION Manila, Philippin es 17-19 February 2003
WPR/1 CP/HRF/6.4/001/H CF(l )/2003 .1 b 12 February 2003
ENGLISH ONLY
PROGRA MME OF ACTIVIT IES Monday, 17 February 0800-0830 0830-0900 Registration Opening ceremony Opening Speech Self-introduction Designation of Chairperson, Vice-Chairperson and Rapporteur Administrative announcements
Group photo 0900-0915 Overall health situation in the Western Pacific Region by Dr Soe Nyunt-U, Acting Director, Health Sector Developm ent Regional overview on health care financing by Mr Dorjsuren Bayarsaikhan, Technical Officer, Health Care Financing Country presentations: Health care financing issues and challenge sChina by Dr Shanlian Hu Fiji by Mr Luke Rokovada Republic of Korea by Mr K. T. Moon Coffee break Country presentations (cont'd.) Malaysia by Dr Rozita Halina Tun Hussein Mongolia by Dr Sodov Sonin Philippines by Ms Maylene Beltran Samoa py Ms Frances Brebner
0915-0930
0930-0945
0945-1000 . 1000-1015 1015-1045 1045-1100
1100-1115 1115-1130 1130-1145
WPR/ICP/HRF/6.4/001/HCF (l)/2003.1b page 2
Monday, 17 February ( cont'd.)
1145-1200 1200-1230 1230-1330
VietNam by Dr Tran Van Tien Discussion Lunch Break Presentations on National Health Accounts (NHA) NHA as a policy tool: Guide for NHA development by Dr Ravindra Raman-Eliya, Sri Lanka NHA development: Challenges and lessons from Samoa by Ms Frances Brebner Use ofNHA in health policy formulation by Ms Maylene Beltran Discussion Cofee Break
1330-1350
1350-1410
1410-1430
1430-1500 1500-1520
Theme 1: Revenue Collection 1520-1600 Presentations Mobilizing financial resources for health care: Ensuring equity by Dr Steve Fabricant Public and private financing in health care: Addressing poverty by Dr Shanlian Hu New opportunities for health promotion financing by Dr Susan Mercado 1600-1700 Discussion
WPRJICPIHRF/6.4/001/HCF(1)/2003.lb page 3 Tuesday, 18 February
T,heme 2: Pooling Financial Resources 0830-0915 Presentations Financial protection through risk-sharing and fund pooling mechanisms by Dr Aviva Ron Achieving universal coverage: Lessons learnt by Dr Sodov Sonin Community health insurance in the Philippines by Dr Marife Yap Fund pooling: The Australian experience by Mr Afsar Akal 0915-1000 1000-1030 Discussion Coffee break
Theme 3: Purchasing health servicesWhat to buy 1030-1130 Presentations Health policy: Priority setting and purchasing by Dr Toshihiko Hasegawa Health care decision-making: Achieving an appropria kinix of services by Ms Carol Beaver How to pay 1130-1200 Presentations Payment mechanisms for health care providers and created incentives by Ms Karen Quigley Questions and clarifications 1200-1300 1300-1345 Lunch Break Presentations Contracting health services in Cambodia by Dr Aye Aye Thwin Formal and informal fees for health care by Dr James Killingsworth Discussion Coffee break Review and summary of last two days and introduction to working groups by Mr Dorjsuren Bayarsaikhan Working groups to discuss and identify strategies and recommendations for regional framework under the themes
1345-1500 1500-1520 1520-1700
WPR/ICPIHRF/6.4/001/HCF(1)/2003.1b page4
Wednesday, 19 February 0800-0930 Working groups to discuss and identify strategies and recommendations for regional framework under the themes Coffee break Continuation - Working group discussion Working group to fmalize strategies and recommendations for regional framework under the three themes Lunch Break Plenary session Reports of the working groups and discussion Coffee break Closing ceremony
0930-1000 1000-1100 1100-1200
1200-1300 1300-1430
1430-1500 1500
ANNEX
~
TAG Meeting on Health Care Financing 17-19 February, 2003, WPRO, Manila
Working Group A Theme: Revenue collection Facilitator: Dr Steve Fabricant Participants: 1. Dr Kai Hong Phua 2. Prof Shanlian Hu 3. Ms Maylene Beltran 4. Prof Takusei U menai 5. Ms. Sylvia C. Fulgencio 6. :rvJ;s. Kaemthong Indaratna 7. Ms Phoung Nguyen Thi Kim 8. Mr Yang Hongwei 9. Ms Anjana Bhushan* * Secretariat assistant
Annex 4
TAG Meeting on Health Care Fina ncin g 17-19 February, 2003, WPRO, Man ila
W or ki ng Gr ou p B Th em e: Po ol in g Fi na nc ia l Re so ur ce s Fa ci lit at or : D r A vi va Ro n Pa rti ci pa nt s: 1. M s Fr an ce s Br eb ne r 2. M r Lu ke Ro ko va da 3.· D r So do v So ni n 4. D r Tr an Va n Ti en 5. Dr. An na Lucia Asanza 6. Mr. Afsar Akal* 7. Dr Ay e Aye Th wi n 8. Dr Th an Sein 9. Dr. Budiono Santoso * Secretariat assistant
TAG Meeting on Health Care Financ ing 17-19 February, 2003, WPRO , Manil a
-
,.). ~
Annex 4
Wo rki ng Gro up C The me: Pur cha sing ~ealth Ser vice s Fac ilita tor: Dr Rav ind ra Ran nan -El iya Par tici pan ts: 1. Dr K. T Mo on 2. Dr Tos hik o Has ega wa 3. Ms Kar en Qu igle y · 4. Roz ita Hal ina Tun Hu ssei n · 5. Dr Eug enio Vill ar Mo ntes inos 6. Dr. Jacques Jeu gma ns 7. Dr J avit Chu wdh ury 8. Dr Susan Me rcad o 9. Dr James Kill ings wor th 10. Ms Carol Bea ver* 11. Dr Gra ham Har riso n 12. Mr. D.B aya rsai kha n * Secretariat assistant
CONSOLIDATED REPORT EVALUATION QUESTIONNAIRE THIRD HEALTH SECTOR DEVELOP MENT TECHNIC AL ADVISORY GROUP MEETING : HEALTH CARE FINANCING IN THE WESTERN PACIFIC REGION Manila, Philippines, 17- 19 February 2003 Total Number of Evaluation Questionnaires Submitted : 22 Area of Evaluation 1. Educational gains 1.1 Were the following objectives met? (a) to review the current situation, main challenges and options to strengthen health care financing arrangements in the Member States (b) to identify Regional strategies with regard to health financing and its three main areas, namely, fund collection, pooling and purchasing (c) to provide recommendations on priority health care financing issues and policy development in the Region 1.2 Have new skills or concepts been learnt at the meeting? 1.3 Can these skills and concepts be applied in your
Response Yes No N/A
·Other Remarks
·-
22 22 21
0 0
0 0
1
0
22 20
"Do we need to be 'prescriptive ' in recommendations or advise the countries in general health financing issues? Example: prescriptive - that equity is the main aim and x percent of health should be government funded"
0 I
0 1 Yes, with some adaptation to suit unique local conditions
country? . 2. Process and outcome 2.1 Were you able to express your ideas or problems at the meeting? 22 0 0
-
2.2 Was there enough opportunity to exchange knowledge and experience with other participants? . 2.3 Were you satisfied with all working papers provided? 2.4 Specify which of the working papers distributed for the meeting are suitable for wider distribution?
21
1
0
Time is too tight
22
0
0
Yes, but if there was more time, some of the issues would be discussed in a detailed way. Suggested papers for distribution: (a) NHA as a policy tool: Guide for NHA development - suggested by 3 participants (b) Financial Protection through fund sharing and risk pooling mechanism- suggested by 4 pax (c) Health care decision making: achieving an appropriate mix of services (d) All papers - suggested by 1 participant (e) Country experience - suggested by 1 participant (f) Overall Health Situation in the WPR (g) Regional Overview on HCF- suggested by 5 (h) Community Health Insurance in the Philippines (i) Formal and Informal Fees for Health Care (j) Challenging inequities in health
•
N
2.5 Did you have enough time to study the working papers? If no, did you receive the working papers sufficiently in advance? 2.6 Were methods of introduction·and presentation of different topics satisfactory? 2. 7 Were you fully satisfied with discussions (a) at the plenary sessions? (b) at the group sessions? 2.8 Field visits 2.8.1 If there were field v.isits as part of the meeting, were they useful to meet the objectives? 2.8.2 If there were no field visits, do you consider field visits would have been useful to meet the meeting objectives? 3. Organization of the meeting Were the duration and scheduling of different activities - lectures, group discussions etc. - satisfactory? 4. Administrative aspect Are organizing or administrative arrangements for travel, accommodation, per diem, meeting room, secretarial support and interpretation satisfactory? 5. Your oveni.ll conclusion Do you feel that (a) The recommendations/conclusions reflected the meeting consensus?
10
12 Yes
0
Presentation should preferably be "presentation by a speaker who speaks, talks and not reads "
21
1
0
Rm 3201 would have been less formal and more interactive
22 21
0 1
0 0
Yes, it could give us the opportunity to see and discuss on concrete realities.
0 6
0 10
22 6
22
0
0
Overall, yes, but may be better to have a bit more time in group discussion for difficult issues.
22
0
0
21
0
1
(b) Such meetings should be held regularly? (c) Your attendance was worthwhile to you personally? (d) Your participation was worthwhile to your country? 6. Is there any better way to achieve the meeting ·· objectives?
20
0 0
2 1 3
Not applicable for TAG- may be different subjects each time Yes, I hope to join this kind of meeting again Other ways: (a) Dissemination of meeting papers as proceedings or compiling in a book (b) Perhaps to consider attending with national counterparts (c) Perhaps one group discussion each day to go more in-depth in each issue (d) More time on discussion and site visit Regular improvements will happen naturally, no need to worry about it too much Meeting becoming more linked to objectives
21 19 8
0
10
4 7. What follow-up activities, 'if any, would you recommend? (a) by national govemment(b) byWHO(c) by other agencies (specify type) National Government: (a) Convert findings into strategies that can be operationalised and institutionalised in country (b) We follow-up with them that they deliver the changes (c) Dissemination of recommendation and fleshing out of operational plans (d) Proceed with health financing planning further (e) Discuss health financing issues at national level among key stakeholders (f) To incorporate into plans (g) Conduct national workshop WHO (a) Workplan based on recommendations · (b) To keep the communication going, share and exchange information
(c) Facilitate and support govemments in the above discussion and generate consensus on key health financing approaches and push them into . operationalisation (d) Concretely follow recommendations of meeting (e) Review all recommendations and develop plan of action, mobilize resources, undertake activities for priority countries, also at sub-regional level. Try to 1ind technical cooperation between countries at different phases (f) Holding continuous dialogue and discussion Other agencies (specify type) (a) Initiate discussion (b) World Bank, ADB and other agencies working in health financing should discuss coordinate with WHO in order to provide governments 1------ - - - - - - - - - - - -- -- -- - -- +-- - with consistent messages and advices 8. How many meetings- WHO and others- have you 0 - 2 meetings: 18 3 - 5 meetings: 2 attended in your professional capacity outside your 6 or more meetings: 2 country over the last twelve months? 1. Would have been useful to have a session on impact ofHCF changes on Additional Remarks disease control programmes- communicable and non-communicable with participants from the Divisions (DHP and DCC