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1 International Health Financing Policies J.-P. Unger Public sector health care unit Institute of Tropical Medicine, Antwerp, Belgium A presentation to.

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Presentation on theme: "1 International Health Financing Policies J.-P. Unger Public sector health care unit Institute of Tropical Medicine, Antwerp, Belgium A presentation to."— Presentation transcript:

1 1 International Health Financing Policies J.-P. Unger Public sector health care unit Institute of Tropical Medicine, Antwerp, Belgium A presentation to Medicus Mundi Spain June, 2013

2 2 Plan 1. International health financing policies in LIC 2. International health financing policies in MIC 3. Alternative options

3 3 1. International policies on health care delivery and financing in LIC

4 4 Alleged objectives of international health policy (MDGs) Reduce mortality by AIDS, TB, malaria Reduce maternal and child mortality Avoid communicable diseases spilling over in HIC

5 5 International health policy forgotten objectives Improve equity in access to care Reduce adult mortality Reduce morbidity and suffering in children and adults Control biological and social determinants of illness Limit spread of resistance to drugs Control health expenditure

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7 7 Failure to reach (the quite limited) MDGs and even to progress in LIC ± 50% of PLWHA needing treatment were receiving the medicines in 2009 (36% with new guidelines), far from the 100% aimed at in 2010 TB prevalence in Africa: : +47% Health care expenditure remains 1st cause of falling into poverty

8 8 Avoidable mortality and suffering 11 million avoidable deaths attributable to communicable diseases yearly ± 10 million avoidable deaths due to chronic diseases yearly Generalised torture – avoidable suffering in LMIC by lack of access to care and drugs (a human right?)

9 9 Inefficiency of international aid More than 120 disease control programs expanded between Washington, Brussels and Geneva LMIC capitals, towns and villages of LIC (with VHW) The biggest ever created bureaucracy

10 10 Total annual resources needed for AIDS under disease-specific organisation pattern Funding gap European Parliament17th March, 2011

11 11 Why this failure to control diseases? A negative feed back loop 1. for success, disease control programmes need patients consulting for various symptoms. They represent a pool of users that disease control programmes need for early case detection and sufficient coverage. Can malaria be controlled where basic health services are not used? Tropical Medicine and International Health, 2006; 11(3): neoliberal policies allocate patients to private sector and disease control to public Letter. Public health implications of world trade negotiations. Lancet, 2004, 363: while disease control programs limit access to care in public services e.g. polarizing them according to their interests A code of best practice for disease control programmes to avoid damaging health care services in developing countries Int J Health Planning and Management 2003, 18: S27-S39

12 12 Why has access to health care been left out of international health policies in LICs? Not because costs: costs of a few disease control programmes in DCs = costs of family medicine encompassing the same programmes Selective Primary Health Care: a critical review of Methods and Results. Soc. Sci. Med. 1986; 22, Because no subsided competition with the private sector is tolerated where there is a demand.

13 13 The international policy undermine LIC health systems Segmentation and fragmentation of systems No more first line individual health care delivery Proliferation of disease specific programs (52 in Congo)

14 14 The international policy undermined health systems in LIC Limited responsiveness of health systems to respond to users demand and to host disease control programs Community participation and support vanished Poor status of public services professionals Internal brain drain (LIC++) International health policy and stagnating maternal mortality: is there a causal link? Reprod Health Matters, 17,33:

15 15 Overall impact on health care 1990: almost 50% fail to provide adequate access to care for their citizens in LIC and MIC UNDP. Department of Economic and Social Affairs, Population Division, United Nations, New York. ST/ESA/SER.R/151, 2000 access to care particularly difficult in China, former Soviet Union, Africa no recent global data (to our best knowledge)

16 16 2. MIC health policies Comparing Colombia, Chile and Costa Rica Colombia, in vivo test of health care privatisation in developing countries. Int J Health Services Costa Rica: Achievements of a heterodox health policy. American Journal of Public Health Chile, a neoliberal success story? PLoS

17 17 Old inter-country comparisons Reduction IMRIMRIMRMMR Costa Rica 629 : 7 29 Chile7810 : 8 23 Colombia6919 : 4 80 Notice: 16% of Chilean population consumes 50% of health expenditure

18 18 Health and Equity Indicators Costa Rica vs United States (2002) GDP per capita (PPP USD) health expenditure per capita Costa Rica 9,460562USA34,3204,887 infant mortality rate 97 life expectancy at birth 7877 Gini index

19 MIC/US health policies: a universal model 19

20 20 The new international health policy objective: universal coverage Promoted by France, Germany, USA… And WHO (WHR 2010) Alleged justifications: out-of-pocket expenditure hampers access chronic diseases become a burden (demographic transition) Objective: open LMIC middle class market of health insurance to high income countries banks Example: main Chilean Isapres belong to 3 EU / US banks

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23 23 Misleading universal insurance coverage Colombia : insurance coverage rate from 54% up to 62% but outpatient consultation rate 23.8% down to 9.5% Peru 2007 – 2008: social Insurance coverage from 42,7 up to 63,5% in extremely poor population and from 26.6 to 44.7 in the other but those who didnt consult increased from 50.5 to 56% Burkina Faso 2008: Made C-sections free at the point of delivery but c-section rate up by 20% only Ghana : insurance coverage increasing from 0% to 60% but user fees increased from 9 to 11% of total health expenditure

24 24 (Insurance!) universal coverage, a fashionable strategy unlikely to work All these examples point to the existence of significant non- financial barriers to access to individual health care limited effectiveness of health insurance in LMIC the lure of focusing public financing on the poor ( Western Europe)

25 25 Why did social health insurances fail in LMIC? Because paradoxically, governments focused public financing / social insurance on the poor! …which led middle classes to deny any contribution to health care public financing as they couldnt take advantage of it To the contrary, in Western Europe, social organizations forced a single universal pooled prepayment system

26 26 Why did social health insurances fail in LMIC? Because of limited effectiveness of regulation and control in LMICs Hesvic project: evaluation of regulation in Chinese, Vietnamese and Indian maternal health sectors 8 / 9 = failures; 1 / 9 = central planning Failure of PFP in Costa Rica Failure of Chilean and Colombian health policies are partly linked to failures of their superintendencia (contraloria) Mechanisms are related to LIC / MIC States features

27 27 The international policy undermine LIC health systems Segmentation and fragmentation of systems Management property split = commercial privatisation of public hospitals (ex. China) Municipalization of health services (from Philippines to Brazil) Bolivia: 4 authorities (national and local governments, region, and international cooperation) for 1 health centre

28 28 The hidden motives of this policy 16% of GDP (USA) – 8% of GDP (Spain)= 8% of the world GDP The biggest worldwide market to earn?

29 Past and future GDP at market prices (trillions of euro) EU ?? 29

30 Non health economic actors will lose market shares if Europe health system moves towards a US like one 30

31 31 Alternative options in health care delivery policies

32 32 A new MDG: universal access to versatile, individual health care family and community medicine general hospital care disease control integrated control of social determinants

33 33 Instead of insurance coverage indicators, promote indicators of access to decent care Examples Hospital admission rates First line utilisation rates TB and AIDS case fatality rates Referral completion rate None of them are requested by WHO / released by countries!

34 34 Such care should meet simple quality criteria Care should be continuous (to avoid resistance to antiretroviral and TB statics) integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs) bio-psychosocial (to be effective /acceptable) effective e.g. tuberculosis case fatality rate Efficient (to be compatible with solidarity) Not-for profit (to be compatible with the Hippocratic Oath)

35 35 Promote a health sector with a social mission Mission (Status) Social (Government) Commercial (Private) MOH Care + Disease control Care private Care + Disease control Care

36 36 Strategic priorities for health systems strengthening 1. Integrate and strengthen the sector of publicly oriented (socially motivated) health care delivery 2. Integrate administration of disease control programs into general health care management 3. Strengthen bio-psychosocial care in first line 4. Strengthen general hospitals 5. Coordinate first line services + Hospital in a local health system to improve care coordination and knowledge transfer 6. Steer field experiments 7. Promote bottom up planning towards national health policy

37 Addressing fragmentation with integrated networks H Interinstitutional management of local health systems Professional management and deconcentrated budgets are needed

38 38 4. Alternative options in health financing Lets not target the poor with public financing if we want national solidarity and equity Lets export the principles of the West-European health financing system

39 39 An alternative financing pattern for segmented health systems Taxes (or Bismarkian) National health fund MoH MoH servicesNot for profit private org. Commercial sector Individuals Social sector Demand- side financing Notice: supply side financing doesnt permit to only finance MOH services


41 41 Thank you

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