S uth-East Asia HEALTH in
HEALTH in
A SEARO Newsletter | September 2013 Vol. 6 No. 2
This issue: Universal Health Coverage
©WHO/Leonardo Ortega
Contents
Message from the Regional Director ����������������������� 3 What is Universal Health Coverage?������������������������ 4 Regional Strategy for Universal Health Coverage���� 6 Measuring UHC: creating a composite index in Bhutan��������������������������������������������������������������������� 8 Improving equitable access through maternal health vouchers in Myanmar��������������������������������� 10 Free access to medicines improving system equity and efficiency in Rajasthan, India�������������������������� 12
© WHO/Monir Islam
Providing good health at low cost in Bangladesh��� 14 Using health technology assessment to inform policy: the economic costs of alcohol consumption in Thailand������������������������������������������������������������ 16 The Health Intervention and Technology Assessment Program (HITAP) Thailand: institutionalizing inclusive and evidence-based decision making using health technology assessments (HTA) .����������������������������������������������� 18 FAQs on UHC������������������������������������������������������� 19
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Message from the Regional Director “The Member States of WHO South-East Asia Region are committed to addressing health inequities and establishing universal health coverage (UHC). The Regional Strategy for Universal Health Coverage endorsed by the Sixtyfifth Session of the WHO Regional Committee 2012 rightly emphasizes equity as its core objective and singles out the principles of primary health care (PHC) as the starting point for reform. Evidence shows that out-of-pocket payment (OOP) for health is a key driver of health-related inequities in the Region. Countries that have progressed well on UHC have reduced OOP to less than onethird of the total health expenditure, with government spending at about 5% of gross domestic product. Countries of the Region have registered impressive achievements on the Millennium Development Goals however there are disparities in these achievements. The Rio+20 Conference in 2012 and subsequently the Sixty-sixth United Nations General Assembly adopted the concept of Sustainable Developments Goals (SDGs) with health as an important precondition and outcome. This is now the umbrella for the post-2015 development agenda debate. UHC must be affordable and sustainable in the long term based on domestic resources. Evidence-based national health policies, strategies and plans play an important role here. Governments must also understand that PHC is considered the most cost-efficient and cost-effective means to address the health needs of their populations. This requires the application of economic principles in tandem with application of public health principles in designing UHC. To support UHC and make it sustainable, a multisector effort needs to be mobilized through a ‘health in all policies’ approach that also effectively consolidates contributions from the private sector, nongovernmental organizations, voluntary organizations and civil society. There is a need for appropriate mechanisms for monitoring of the progress and for objective evaluation of the impact of UHC on equity in health and the impact on people’s status. WHO will continue to work with Member States to pursue UHC in order to enhance health gains and achieve sustainable human development.” Abstract from Opening remarks Universal Health WHO Regional New Delhi, India. the Regional Director’s on Technical Discussions on Coverage, 10–12 July 2013, Office for South-East Asia,
Dr Samlee Plianbangchang Regional Director
What is Universal Health Coverage? The goal of universal health coverage (UHC) is to ensure that all people have access to the health services they need without suffering financial hardship. For a community or country to achieve UHC several factors must be in place, including: zz
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early detection and diagnosis; adequate capacity disease; and helping patients rehabilitation. to treat with
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A strong, efficient, well-run health system that meets priority health needs through people-centred integrated care by: }}
Affordability: a system for financing health services so people do not suffer financial hardship when using them. Access to essential medicines and technologies to diagnose and treat medical problems.
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informing and encouraging people to stay healthy and prevent illness;
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© WHO/Myanmar
Universal Health Coverage
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A sufficient capacity of well-trained, motivated health workers to provide the services that meet patients’ needs, based on the best available evidence.
attendance. Financial risk protection can also protect people from impoverishment as a result of health service costs. UHC is a critical component of sustainable development, poverty reduction and equity. It can be the hallmark of a government’s commitment to improve the well-being of its citizens. UHC is firmly based on the WHO constitution of 1948, which declares health a fundamental human right.
UHC also requires recognition of the critical role played by all sectors in assuring human health, including transport, education and urban planning; that good health enables people to be more productive and active contributors to their families and communities, and encourages more consistent school
The 4As of UHC Affordability Accessibility
High Quality People-centered and Integrated Care Acceptability Availability
Source: What is universal health coverage? Online Q&A, October 2012. Geneva: World Health Organization (http://www.who.int/features/qa/universal_health_coverage/en/, accessed 14 August 2013).
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Regional Strategy for Universal Health Coverage A conceptual strategic direction: 1. Placing primary health care-oriented health systems strengthening at the centre of UHC. The definition and principles of primary health care (PHC) are consistent with informing strategic choices along three dimensions: a benefit package that gives priority to the health needs of the poor and public health, delivered using appropriate technology and at sustainable cost. Two technical strategic directions: 2. Improving equity through social protection. Experience suggests that reducing inequities involves reducing out-of-pocket health spending by adopting pre-payments with consolidated pooling (through tax-based funding) and/or social insurance schemes. Recommendations from the South-East Asia Regional Consultation of NGOs and Civil Society on Post-2015 Health Development Agenda, 28 February to 1 March 2013, New Delhi, India �
Overall health outcome goal: by 20XX all countries should reduce the number of healthy life years lost by their population by n%. Overarching health sector goal (to help achieve the above): by 20XX all countries should achieve universal coverage of a package of preventive, curative and rehabilitative health services whereby all people receive the services they need without suffering financial hardship.
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© WHO/Rajiv Kumar
Universal Health Coverage
3. Improving efficiency in service delivery. Improving efficiency in service delivery is equally relevant for achieving UHC. It determines what services are provided and at what cost, as well as who has access to them. In South-East Asia, shifts are taking place from low-cost approaches (including prevention/public health) towards higher cost curative care. Restoring an appropriate balance will be key for sustainable UHC and requires attention to all areas of the health system. An operational strategic direction: 4. Strengthening capacities for UHC. Evidence-based decision-making requires capacities to monitor and evaluate, and these need to be strengthened in many countries. Source: Regional Strategy for Universal Health Coverage. WHO Regional Office for South-East Asia, New Delhi, India: 2012.
Report of the Regional Consultation on the Post 2015Development Agenda, 19–21 March 2013, Bangkok, Thailand �
Human well-being and happiness was identified as the overarching goal for the post-2015 development agenda. For the unfinished MDG agenda and the growing problems of noncommunicable diseases, a lifecourse approach and continuum of care was recommended, balancing prevention, promotion, curative, palliative and rehabilitative care. To achieve UHC, systems based on the primary health care need to be strengthened to improve efficiency in service delivery, and mobilize adequate human resources and equitable financing through good governance.
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© WHO/Pallava Bagla
Measuring UHC: creating a composite index in Bhutan Approach Key indicators on 3 UHC dimensions � �
Shortlist of 15 indicators Shortlist criteria: (1) FYP inclusion; (2) UHC dimensions fit; and (3) sub national assessment Assessment of the data gaps Indicator values/estimates Data sources: � Quantitative: BHMIS, Annual Household Surveys, national surveys � Qualitative: Open ended interviews (n=20), national reports, PubMed (237/5) Gaps in data and methods (Findings 1) Preliminary estimates on 3 UHC dimensions (Findings 2) Recommendations for way forward on monitoring UHC UHC index
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Data and analysis
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Findings and way forward
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A visualization of the “UHC index” Identi able service availability and population coverage gaps, and requirement for ongoing careful monitoring of nancial protection. Financial protection 90%
Wide population coverage, but spatial and socioeconomic gaps, particularly for maternal health – also limited NCD services
Widespread service availability , but lack of de nition of clear bene ts package, & limited NCD services
High nancial protection with 12% OOP, universal free health care but declining share of GDP below 5% for health and concerns re garding indirect costs
Service availability 70%
Population coverage 73%
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Universal Health Coverage
Population coverage % Districts with DPT3 coverage > 80% % With 4 antenatal care visits % Delivery at facility Out patient department contacts % Population living within 3 hours walk of facility % Women aged 20–60 screened by pap smear at least once TOTAL RESULT Service availability % Facilities providing essential package according to standards % Dzonhkhags > 2.3 staff per 1000 population % Dzongkhags with stock out of 10 essential drugs or more in last 12 months Patient Satisfaction rate at facilities National OPD waiting time from 9 to 11 am TOTAL RESULT Financial protection % out of pocket expenditures on health Health expenses as % of nominal GDP Govt health expenditure (GHE) as % of total govt expenditure (THE) Constitutional Policy Commitment to UHC TOTAL RESULT
Data source BHMIS 2011 BHMIS 2011 BHMIS 2011 BHMIS 2011 BHMIS 2012 BHMIS 2011, 11th 5 Year Plan
Indicator result 2011 19 out of 20 Dzongkhags 77% 63% 3.1 (if > 3 per capita =2) 76% 25%
Weight 1 1 1 2 1 1 7
Score 0.90 0.77 0.63 2.00 0.76 0.25 5.31 76%
Estimate only HRD Database BHMIS Report 11th 5 Year Plan 11th 5 Year Plan
80% 8 out of 19 Dzongkhags 14 out of 19 Dzongkhags 85% with target of 95% Maintain at 23 minutes
5 1 1 1 1 9
4.00 0.42 0.26 0.85 1.00 6.53 73%
NHA 2010 NHA 2010 NHA 2010 Health Policy 2010
NHA Estimate 3.68% (target of 5%) 5.6% (target of 8%) Yes
1 1 1 2 5
0.90 0.74 0.70 2.00 4.64 87%
Source: Presentation by Mr Jayendra Sharma, Ministry of Health, Royal Government of Bhutan, at the Technical Discussions on UHC, 10-12 July 2013, WHO South-East Asia Regional Office, New Delhi, India.
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Improving equitable access through maternal health vouchers in Myanmar In Myanmar, there are over 900 000 pregnancies annually, of which only 68% and 50% respectively receive antenatal care and delivery services by skilled birth attendants. This leads to morbidity and mortality during pregnancy and childbirth. Although maternal and child health (MCH) services are provided free of charge by the Government, there were severe shortages of medical and surgical equipment (e.g. antibiotics and clean delivery kits), which resulted in clients needing to pay outof-pocket for essential equipment from private pharmacies. In addition, MCH care providers were often voluntarily paid by clients in order to compensate for inadequate provider salaries and the costs of travelling. Household MCH expenditure is
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© WHO/Shehzad Noorani
Universal Health Coverage
To address this financial barrier, the Government is introducing an MCH voucher scheme in which pregnant women receive free services form health care professionals such as midwives or medical officers. The vouchers can be reimbursed by service providers for cash from the Ministry of Health. It is estimated that the voucher scheme could save the lives of 1 mother and
4 infants for every 1000 pregnant women using the scheme. It is also expected that maternal and infant morbidity will decline significantly as a result of increased access to services of skilled birth attendants.
Estimates suggest the voucher scheme could save the lives of 1 mother and 4 infants for every 1000 pregnant women
Source: Health Intervention and Technology Assessment Program (HITAP) (2010). A feasibility study of the Community Health Initiative for Maternal and Child Health in Myanmar (2010). HITAP, Ministry of Public Health, Bangkok, Thailand.
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© WHO/Shehzad Noorani
significant, ranging from 28 000 Myanmar Kyats for delivery assisted by non-skilled birth attendants to 32 000 Kyats for delivery assisted by skilled-birth attendants at home. The majority of pregnant women and new mothers (67%) found difficulties in raising the funds necessary to cover these costs. It was found that 39% of pregnant women and new mothers needed to borrow money from others; 17% forewent essential food consumption; and 13% sold or pledged crops or gold in order to pay for the MCH services.
Free access to medicines improving system equity and efficiency in Rajasthan, India In India, out-of-pocket payments for health comprise 70% of total health expenditure, 70% of which are for the purchase of medicines. Further, medicines procurement, pricing, distribution and dispensing also contribute to reinforcing systems inefficiencies. Multiple mark-ups on the cost of medicines can be exacerbated by the estimated 50% irrational use of medicines in the Region. Recognizing the need to address these barriers, the Government of Rajasthan launched the Mukhyamantri Nishulk Dava Yojana (MNDY) in October 2011: a step towards making treatment affordable for the entire population of the state through free provision of essential medicines. Under the scheme, generic versions of 400 essential medicines – which are used to treat about 90% of the most common illnesses – are provided to all patients using Government-run public health facilities. The plan is to increase the list to 600 medicines in due course. Given the ambitious nature of the scheme, a structured framework was put in place holistically addressing all systems building blocks in a time bound manner – including monitoring, which crucially targets changes in behaviour on both supply and demand sides.
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© WHO/Sophie Bergerson
Universal Health Coverage
Components of Free Medicines Scheme (Hardware component) (Software component)
(A). To make drugs available in Government hospitals 1 2 3 4 5 6 7 8 9 Establishment of autonomous centralized procurement agency: Rajasthan medical services corporation Identification of drugs for free essential drug list Procurement through a two-bid transparent e-tendering process Drug warehouse at every district Empanelled laboratories for quality testing System for transportation of drugs System for storage and distribution of drugs in all hospitals e-Aushadhi Software for inventory management Transparent and prompt payment system
(B). To change prescription behaviour of doctors Sensitization and orientation about rational use of drugs Write prescription on self carbonated prescription slips Diagnosis must be written Write generic/salt names Use from Essential Drug List Follow standard treatment guidelines Constitution of Drug and Therapeutics Committee (DTC) Prescription audit Computerized drug dispensing up to PHC Patient counselling
10 Sufficient funds
Source: Presentation by Dr Samik Sharma, Rajasthan Medical Service Corporation, at the Technical Discussions on UHC, 10-12 July 2013, WHO South-East Asia Regional Office, New Delhi, India.
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© WHO/John Hasyn
The Government of Rajasthan launched the Mukhyamantri Nishulk Dava Yojana (MNDY): a step towards making treatment affordable for the entire population of the state through free provision of essential medicines
Providing good health at low-cost in Bangladesh Bangladesh has made impressive progress on health indicators at low cost, offering some useful lessons for other countries in the Region. Compared with other countries in the same income group, Bangladesh has among the longest life expectancy for men and women, the lowest total fertility rate and the lowest infant, under-5 and maternal mortality rates. These health gains have been made with relatively low total health expenditure of 3.4% of GDP or US$ 12 per capita (2007 data). Health gains are attributed to strong political commitment, insightful investment in human resources for health, implementation of innovative service delivery methods, and developing, implementing and scaling up of low-cost interventions like zinc for treatment of childhood diarrhoea, oral
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© WHO/Rajiv Kumar
Universal Health Coverage
rehydration salts, tetanus vaccination for pregnant mothers, safe delivery kits and iodized salt. In addition, effort to reach the unreached and disadvantaged groups through a diverse mix of public and voluntary provision of health services has complemented this effort. Bangladesh now must apply the same formula of low cost and less complex interventions to address the increasing burden of noncom municable diseases as well as to the health of the growing elderly population.
Lessons from Bangladesh reveal that better health of the population can be achieved through four Cs: Capacity (the individuals and institutions necessary to design and implement reform); Continuity (the stability that is required for reforms to succeed); Catalysts (the ability to seize windows of opportunity); and Context (the ability to take context into account in order to develop appropriate and relevant policies). Source: Balabanova et al. (ed) (2011). Good health at low cost. Charlesworth Press, Wakefield, United Kingdom.
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© WHO/Vismita Gupta-Smith
Using health technology assessment to inform policy: the economic costs of alcohol consumption in Thailand This is a prevalence-based, cost-of-illness study. The estimated costs in this study included both direct and indirect costs. Direct costs included health care costs, costs of law enforcement, and costs of property damage due to road-traffic collisions. Indirect costs included costs of productivity loss due to premature mortality, and costs of reduced productivity due to absenteeism and ‘presenteeism’ (i.e. reduced on-the-job productivity). The total economic cost of alcohol consumption in Thailand in 2006 was estimated at 156 105.4 million Baht (9627 million US$ PPP) or about 1.99% of the total gross domestic product (GDP). Indirect costs outweigh direct costs, representing 96% of the total cost. The largest cost attributable to alcohol consumption is that of productivity loss due to premature mortality (104 128 million Baht/6422 million US$ PPP), followed by cost of productivity loss due to reduced productivity (45 464.6 million Baht/2804 million US$ PPP), health care cost (5491.2 million Baht/339 million US$ PPP), cost of property damage as a result of road traffic collisions (779.4 million Baht/48 million US$ PPP), and cost of law enforcement (242.4 million Baht/15 million US$ PPP), respectively. The results from sensitivity analysis revealed that the cost ranges from 115 160.4 million Baht to 214 053.0 million Baht (7102.1 to 13 201 million US$ PPP) depending on the methods and assumptions employed.
Promoting alcohol abstinence
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©Ministry of Public Health, Thailand
Universal Health Coverage
Cost of property damage 0.50% Health care cost 4% Law enforcement cost 0.16% Cost of reduced productivity 29%
Cost of premature mortality 67%
Excise tax
156 000 MILLION BHATT
70 000 MILLION BHATT
Alcohol imposes a substantial economic burden on Thai society, and according to these findings, the Thailand Government should pay significantly more attention to implementing effective alcohol policies/interventions in order to reduce the negative consequences of the harmful use of alcohol
Source: Thavorncharoensap et al. BMC Public Health 2010; 10:323.
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The Health Intervention and Technology Assessment Program (HITAP) Thailand: institutionalizing inclusive and evidence-based decision making using health technology assessments (HTA) Civil society Patient groups Academic sectors
Health professional Industry No. of people affected Disease/health problem severity Effectiveness of technologies Variation in practice Financial impact to the households Equity/ethical implications (affected by the poor and rare disease condition)
Policy makers General population
Representatives of stakeholder groups as working group on HTA topic selection Submitted topic
Working group on HTA topic selection Prioritized topic Subcommittee on development of health benefit package and services system of National Health Security Offices Final decision Health benefit package development Final topic for HTA
HITAP/IHPP HTA report
1. Cost effectiveness 2. Budget impact
Source: Presentation by the Health Intervention and Technology Assessment Program at the Technical Discussions on UHC, 10-12 July, WHO Regional Office for South-East Asia, New Delhi, India.
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Universal Health Coverage
FAQs on UHC Is UHC only about treatment? Does UHC mean immediate free coverage for all possible health interventions, regardless of the cost?
UHC is not only about treatment. It also includes prevention, promotion, rehabilitation and palliative care. In terms of prevention and promotion, UHC includes both personal and non-personal health services including population based interventions, such as anti-smoking campaigns. Is UHC only about health financing?
Appropriate health financing strategies are essential to enable countries to move closer to UHC, but they are not sufficient by themselves. All components of the health system must be involved. If there are no medicines or health technologies, health workers, health facilities or communication networks, health service delivery systems, quality assurance mechanisms, systems of governance and legislation then UHC cannot be achieved. What services should be included in UHC?
The road to UHC requires progressive realization of people’s right to health where coverage with health services and financial risk protection are progressively expanded as more resources become available. The goal should be to provide an increasing number of health services over time, while at the same time reducing out-of-pocket costs to patients. How can UHC contribute to continued progress on the current MDGs while taking into account new health priorities?
Essential health services should be available to all who need them. Decisions about which services can be guaranteed to the population initially, and which ones should be added over time, are based on people’s needs, public opinion and costs.
Moving closer to UHC requires increasing equitable access to all types of needed health services. This implies continuing efforts to increase the availability and quality of services linked to the current MDGs, such as for HIV/ AIDS, tuberculosis, malaria, child health and maternal health. It also requires considering ways to improve availability, quality and access to key interventions targeting newer health priorities, including noncommunicable diseases and injuries.
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Prepared by: Health Economics & Health Planning Unit, Department of Health Systems Development Produced by: World Health Organization South-East Asia Regional Office
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