1. Shaping UHC Policy for Post 2015: Opportunities & Risks Jeanette Vega MD, DrPH Managing Director of Health NHIS 10 Anniversary Conference Accra, November 4 th, 2013

2. 2 Universal Health Coverage (UHC) contribution to the Sustainable Development Goals UHC: Definition and components Health financing situation in Africa Presentation Overview Achievement of MDGs in the region Concluding remarks

3. 3 Universal Health Coverage Health promotion, prevention, treatment, financial risk protection. Healthy Lives at All Stages Child survival, maternal survival, MDG6, adolescent health, NCD burden reduction. Sustainable Wellbeing for All Poverty eradication, health, education, nutrition, environment, security, etc. Health Sector Contribution Other Sector Contributions Post-2015 Development Agenda: Wellbeing for All The contributions of the health sector and other sectors

4. 4 Universal Health Coverage: What? Indicators: 1.Financial protection 2.Access All people can access the health services they need without incurring financial hardship. Definition:

5. 5 Financing for UHC: Overall questions to be addressed by any country How to alter the system in a way that – Reduces the gap between the need for and use of services, across the population, – Improves quality of health services, – Improves financial protection… … given our starting point in terms of – existing configuration of the health system, including coverage arrangements, – overall current and expected fiscal constraints, and – other key contextual factors, such as labor market (informality), public administration structure (e.g. decentralization), geography and population density, politics, etc.? 1 2

6. 6 Policy options for universal funding coverage Fund coverage for everyone secured from general budget revenues, automatic entitlement: Non- contributory 100% Contributory: No subsidy; everybody must contribute a “full premium” or has no entitlement Guarantee (fund from budget) certain services for all; entitlement to “full package” requires contribution – Complementarity between direct contributions and government subsidies for coverage expansion Subsidized participation with strong public commitment to universality 1 2 3 4

7. 7 Two conditions for financing UHC when using contributory arrangements Subsidization: because some will be too poor or too sick to be able to afford coverage Compulsory contribution: because some who can afford it are unwilling to pay for it 1 2 One without the other won’t work (subsidies alone not sufficient because rich/healthy will not join; and compulsory without subsidies imposes a heavy burden on the poor and sick)

8. 8 Some broad lessons on health financing policy No country gets to UHC via voluntary health insurance – Compulsory or automatic entitlement is essential, with subsidies All countries with universal health coverage rely in whole or in part on general budget revenues – Because there are always some who can’t contribute directly, – And the larger the informal sector, the greater the need for using general revenues Need to manage resources efficiently: Strategic purchasing is essential – Move away from the extremes of provider payment methods – unmanaged fee-for-service and rigid line item budgets – as these contribute to system inefficiencies 1 2 3

9. 9 Common elements of few countries that have high coverage with “voluntary”contributory schemes Cost of the “premium” much less than the perceived value of the benefit, stimulating demand – Substantial subsidies on the supply side and the demand side, and same benefit package as rest of population in the scheme – Population aware that not being covered means risk of high out- of-pocket spending Strong role of local governments – Strong incentives/instructions for local officials to inform people and enroll them into the coverage program, (ie. Rwanda), and – Explicit role for local budgets to subsidize (ie China) Very strong (authoritarian) governments able to implement these measures

10. 10 Average per country globally =11.5%, Ghana= 11,9% African governments increasingly giving priority to health. Health as a % of government expenditure

11. 11 African countries have low public spending on health relative to the size of the economy Ghana is lower than the average globally =2.6% Total government expenditures on health as a % of GDP Average per country globally= 3.9%

12. 12 It matters because higher public spending on health reduces dependence on out-of-pocket spending

13. 13 In summary: two critical issues to increase financial access coverage in Africa All people can access the health services they need without incurring financial hardship. How to increase overall fiscal space for health and increase health as a priority in the general budget 1 2 How to advance towards pre-paid Universal financial coverage

14. 14 Achievement of MDGs in the region

15. 15 Reduce by two-thirds the <5 mortality rate between 1990 and 2015

16. 16 Reduce by three quarter the maternal mortality rate between 1990- 2015 Target : 213 per 100,000 livebirths Only 2 countries on track: Eritrea Equatorial Guinea

17. 17 Maternal health: Increase % of skilled birth attendance to 80%

18. 18 One reason for no achievement has been the absence of UHC as a goal in the current objectives Universal Health Coverage is an integrated, efficient approach to improve health outcomes. It is aspirational, but there is growing global and national commitment to UHC. UHC reflects health sector’s inherent responsibility to provide universal and equitable access to health that ensures improved health outcomes. UHC links to other sectors, and enables healthy, sustainable development. UHC is a recommitment to health as a human right. 1 2 3

19. 19 Why UHC in the Post 2015 Development Agenda? When designed with an equity, rights and fiscally prudent focus, UHC is an accelerator towards better health outcomes and overall social wellbeing.

20. 20 MDGs + more ambitious health outcome targets. – E.g., ending preventable maternal and child deaths, universal access to reproductive health, new HIV, TB, malaria targets, NCDs and their risks. Universal health coverage emerging as the specific health sector contribution to health Equity – realizing the right to health for all. Recognition that achieving health outcome targets a require actions beyond the health sector – determinants of health. – E.g. income distribution, education and labor policies, food security and nutrition, water and sanitation, urbanization. Emerging Consensus on Health in the Post-2015 Development Agenda?

21. 21 Processes Feeding Into the Post-2015 Development Agenda Source: UN Foundation and Dalberg analysis