1. Universal Health Coverage
Done by: Dr Rakan Ekram
MBBS, MHP

2. World Health Report 2010
Health Systems Financing: the Path to Universal Coverage
was launched on 22 November 2010
Builds on WHO Constitution; Alma Ata and Health for All; WHR2008 on Primary Health Care

3. World Health Assembly Resolution 58.33, 2005:
Urged countries to develop health financing systems to:
Ensure all people have access to needed services
Without the risk of financial catastrophe linked to paying for care
Defined this as achieving Universal Coverage

4. WHR 2010: Universal Coverage
WHR topic based on World Health Assembly Resolution in 2005
The Resolution defined “Universal Coverage” as coverage with: needed health services; financial risk protection; for everyone.
The aspiration to attain universal coverage is not new. You find reference to it in: WHO's constitution-1948; Alma-Ata Declaration-1978; World Health Report on Primary Health Care-2008 etc
The resolution also states that universal (health) coverage can not be achieved without a well-functioning health financing system

5. Background once in a lifetime opportunity
It will cost money – in low-income countries, increases in external financial will be necessary unless exceptional growth
Nevertheless, virtually all countries could raise or spend more on health if they wished - Sanjay Gupta IMF gave options for raising and spending wisely

6. Two components of Coverage
Coverage with needed services
Coverage with financial risk protection

7. The Objective: Universal Health Coverage
All people have access to needed services
Without the risk of financial ruin linked to paying for care
Universal Health Coverage:
coverage with needed health services (of good quality);
coverage with financial risk protection
for all

8. What role does health systems financing play?
Three inter-related explanations linked to health system financing
Insufficient funds for health in some settings
Too much reliance on direct out-of-pocket payments to finance health – limited financial risk protection
Inefficiency and inequity in use of resources

9. Financial Risk Protection
Requires:
Prepayment and pooling of resources - compulsory
Minimizing user fees and charges – zero for the poor and vulnerable (possibly "negative fees")
Good quality services are available
2. The combination of financial risk protection with the availability of good quality services – instrumental to increasing health and economic wellbeing, but also valued for its own sake

10. Resource Scarcity and Progressive Universalism

11. 1. Dimension: Financial Protection
Millions suffer financial ruin when they use health services:
Globally around 150 million suffer severe financial hardship/ catastrophic health expenditures each year.
100 million are pushed into poverty because they must pay out-of-pocket at the time they receive health services.

12. 2. Dimension: which services are covered?

13. 3.Dimension: who is covered?

14. Proposing solutions: the WHR 2010
The WHR-2010 proposes three inter-related health financing strategic options for universal coverage:
- Raise sufficient funds for health: More money for health
- Reduce heavy reliance on direct OOP: More equity for health.
Reduce and eliminate inefficient use of resources: More health for the money

15. Problem 1: Insufficient funds
A set of essential health services focusing on the Millennium Development Goals would cost on average US$ 44 per capita in low-income countries in 2009, rising to US$ 60 in low income countries spent less than US$ 35 per person (2008)
Only 8 have any chance of reaching the required funding from domestic sources by even assuming rapid growth of their domestic economies.

16. Options for raising more domestic funds for health
Increase the priority given to health in government budget allocations
MoHs often not powerful enough – loose out in budget negotiations
Raise revenue for health more efficiently – e.g. increase the total availability of resources (strong tax base)
In Indonesia, clear and consistent regulations and a policy of zero-tolerance for corruption increased tax yield from 9.9% to 11% of GDP over four years – with a subsequent increase in health expenditures.

17. Options for raising more domestic funds for health
Find new sources of domestic funds e.g.
"Sin" taxes on tobacco and alcohol: a 50% increase in tobacco tax alone would yield an additional US$ 1.42 billion - this could increase government health expenditure by up to 25%.
Excise tax on unhealthy food – Romania – 20% on foods high in fat, salt, sugar
Levy on currency transactions would be feasible in countries with large markets – e.g. India could raise US$ 370 million per year from a very small levy (0.005%).
Levy on remittance transactions - Gabon
Levy on large/ profitable companies – Australia (mining companies); Pakistan (pharmaceutical companies), Gabon (mobile ph. companies).

18. Problem 2: Heavy reliance on direct OOPs
The WHR-2010 proposes three inter-related health financing strategic options for universal coverage:
- Raise sufficient funds for health: More money for health
- Reduce heavy reliance on direct OOP: More equity for health.
Reduce and eliminate inefficient use of resources: More health for the money

19. Options to reduce the impact of OOPs
Reducing OOPs requires switching to systems of “prepayment” with subsequent “pooling” of revenues (Prepayment means paying before illness – and it can take the form of taxation or insurance – Beveridge/ Bismarck/ mix). PREPAYMENT
There seems a minimum level of compulsory prepaid funding that is necessary to ensure that the poor and vulnerable are covered: ca. 4-6% of GDP. See WHO WPRO benchmark: “Universal coverage is difficult to achieve if public financing is less than 5% of GDP”. MINIMUM
Community and micro-insurance can play a useful role in the early stages, but plans to merge them over time are important - bigger pools are more financially viable than small community-based pooled funds. CONSOLIDATE POOLS AND REGULATE

20. Options to reduce the impact of OOPs
Options in addition to prepaid and pooled resources to ensure
greater coverage and lower financial barriers:
Free or subsidized services (e.g. through exemptions or vouchers) for specific groups of people (i.e. the poor) or for specific health conditions (i.e. child or maternal care).
Subsidized or free insurance contributions for the poor and vulnerable.
Cash payments to cover for ex. transport costs for the poor.

21. Problem 3: Inefficiencies
1. Medicine: underuse of generics and higher than necessary price.
2. Medicine: use of substandard and counterfeit medicines.
3. Medicine: inappropriate and ineffective use.
4. Products and services: overuse/supply of equipment, diagnostic services and procedures.
5. Health workers: inappropriate or costly staff mix, unmotivated workers.
6. Health service: inappropriate hospital admission and length of stay.
7. Health service: inappropriate hospital size and low use of infrastructure.
8. Health service: medical errors and suboptimal quality.
9. Health system leakages: waste, corruption and fraud
10. Health intervention: inefficient mix and inappropriate level.

22. Options to encourage greater efficiency
For example:
Paying providers: move away from fee for service if possible. Consider results-based payment where good monitoring is possible etc.
Medicines: improve prescribing guidance, training of staff; incentives for generic substitution; regulate promotional activities, more public information (irrational use) etc.
Health services/ governance: Provide more continuity of care, monitor hospital performance, improve regulatory capacity
Reduce duplication – avoid “fragmentation” with - Funding channels; - Laboratory systems; - Auditing and monitoring systems; - Reporting systems including reporting to donors (Aid effectiveness principles

23. Greater efficiency includes comprehensive health plans
National
health
plans

24. Progressive Universalism: Features
The poor and vulnerable should be covered from the start – do not start with insurance for the formal sector and civil servants with the intention of bringing in the poor and informal sector later
Start by covering interventions against infectious diseases, targeting RNMCH, expanding to NCDs rapidly – the most highly cost-effective interventions
Limited if any payments at the point of service – poor and vulnerable exempted if fees are charged
Expand health services over time as rapidly as possible – prevention, promotion, treatment, rehabilitation, palliation

25. Country Choices: Practicality and Politics
Begin by targeting poor and vulnerable versus universal from the start – practical questions: how easy to identify, restrict
Ways of ensuring poor can afford: zero user fees/co-payments vs. exemptions (or cash transfers) – efficiency question
What to call compulsory prepaid contributions: taxes, charges or compulsory insurance? Sometimes people more willing to contribute to a tax called insurance than pay increases in overall taxation used to fund health
How many pools? Less fragmentation better
How to purchase services from pooled funds: fee for service inefficient, what role for results based payments?

26. What Does Not Work
Voluntary insurance cannot get to UHC – at best, a supplement to compulsory pooling
Catastrophic insurance – e.g. insurance for unpredictable high cost items such as inpatient care - cannot get to UHC

27. Thank YOU