1. GDP and Budgeting for Health Benefits Plans: Roundtable Discussion on Universal Health Coverage Amanda Glassman Director of Global Health Policy Center for Global Development December 6, 2013

2. Source: WHOSIS, 2013 In Latin America, per capita public health spend has slightly increased over time in some countries and dramatically increased in others 2 Per Capita Public Spending on Health by Country (PPP int. $), 1995-2011 — Average — Trinidad & Tobago — Costa Rica — Panama — Uruguay — Guatemala — Nicaragua — Honduras — Bolivia — Argentina For the highest spenders, consistent growth began around 2003

3. Source: World Bank, 2013 Public health spend as a proportion of GDP has remained relatively flat in most Latin American countries with one exception – Costa Rica 3 Public Spending on Health by Country (% GDP), 1995-2011 — Average — Costa Rica — Panama — Uruguay — Nicaragua — Venezuela — Guatemala — Argentina

4. *Or most recent year Sources: WHOSIS, 2013; World Bank, 2013; Economic Commission for Latin America and the Caribbean, 2013; OECD Stats Extract, 2013 Social spending has grown faster than public spending on health and education in both Latin American and OECD countries 4 Public Spending on Health, Education, and Social Protection (% GDP), 1995-2010 1995200020052010 * = Health = Education = Social

5. Source: WHOSIS, 2013 Public health spend as a proportion of total government expenditure varies from 5% to 31% across Latin American countries 5 Public Spending on Health by Country (% Total Government Expenditure), 2009

6. Public Spending on Health by Country (% Total Government Expenditure), 1995-2009 Source: WHOSIS, 2013 In Colombia, share of public spending on health decreased in the late 1990s and has remained flat since 2001, while in Guatemala has increased modestly 6

7. Note: Dotted lines = average Sources: World Bank, 2013; WHOSIS, 2013 Within a certain threshold, greater public health spend does not directly translate into health gains, such as life expectancy 7 Life Expectancy (Years) vs. Per Capita Public Spending on Health (PPP int. $), 2011 Better outcome, Lower expenditure Better outcome, Higher expenditure Worse outcome, Lower expenditure Worse outcome, Higher expenditure

8. Sources: WHOSIS, 2013 Private health spend as a proportion of total health expenditure ranges from 25% to nearly 65% 8 Per Capita Expenditure on Health by Country (PPP int. $), 2011

9. Source: Glassman and Chalkidou, “Priority-Setting in Health: Building institutions for smarter public spending,” a report of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group, 2012 Several, but not the majority, of Latin American countries have an explicit health benefits plan such as health insurance schemes and tax-funded systems 9 Low- and Middle-Income Countries with Health Benefit Plans

10. Note: List of Latin America & Caribbean countries are those included in the World Bank’s country and lending group (developing only) Source: WHO National Medicines List/Formulary/Standard Treatment Guidelines (http://www.who.int/selection_medicines/country_lists/en/), 2013http://www.who.int/selection_medicines/country_lists/en/ Most Latin American and Caribbean countries have a national essential medicines list (NEML) 10 Countries with NEMLCountries without NEML Argentina Belize Brazil Chile Colombia Dominican Republic Ecuador El Salvador Guyana Haiti Antigua and Barbuda Bolivia Costa Rica Cuba Dominica Grenada Guatemala Panama St. Lucia Honduras Jamaica Mexico Nicaragua Paraguay Peru St. Vincent and the Grenadines Suriname Uruguay Venezuela

11. Source: NITAG Resource Center (http://www.nitag-resource.org/en/observatory/dashboard.php), 2013http://www.nitag-resource.org/en/observatory/dashboard.php Very few Latin American countries have a national advisory committees on immunization 11 Chile Peru Honduras Countries with a National Immunization Technical Advisory Group (NITAG)

12. Issues related to explicit plans and lists in Latin America Plans or lists with limited connection to budgets and beneficiaries – Connected: Colombia’s POS – Not connected: Peru’s PIAS Incremental costs of introduction of new interventions and technologies not known, baseline costs and effectiveness not known – What are we comparing to? Process too often ad hoc Many instances of known c/e interventions not funded at scale, while examples of not c/e interventions receiving subsidy International guidance limited, mostly c/e information from other contexts, lack of attention to affordability Decentralized, fragmented purchasing means unexplained variations in the standard and costs of care 12

13. Sources: World Bank, 2013; Giedion, Panopoulou, and Gomez-Fraga, Diseño y ajuste de los planes explícitos de beneficios: el caso de Colombia y México (www.eclac.org/publicaciones/xml/8/37988/lcl3131pe.pdf), 2009www.eclac.org/publicaciones/xml/8/37988/lcl3131pe.pdf Mexico’s Catálogo Universal de Servicios de Salud grew from 91 to 266 interventions, while the capitation payment was only adjusted for inflation 13 Number of Interventions on Health Benefits Plan and Inflation (Annual %) in Mexico, 2004-2008 Inflation (Annual %)

14. Source: Glassman and Chalkidou, “Priority-Setting in Health: Building institutions for smarter public spending,” a report of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group, 2012 Latin American countries with health technology assessment agencies (HTA) select topics on an ad hoc basis 14 HTA in selected middle-income countries: How and why topics are selected Country/EntityPrioritization process for topic selection Brazil/ANVISA/CITEC No formal process. The definition of priorities has been made through an Annual Workshop on Priorities Chile/CCA No formal process. Topic selection is carried out by the CCA Colombia/CRES No preestablished process for topic selection. In 2011 for the first time a more systematic process was used, but this has not been institutionalized Colombian Law Uruguay/FNR/MoH There is no formal process for topic selection. Both the MoH and the FNR define the topics Thailand/HITAP Representatives of four groups of stakeholders (health professionals, academics, patient groups, and civil society organizations) are appointed to sit on a panel overseeing intervention prioritization. Panel introduces six agreed criteria. A scoring approach with well-defined parameters and thresholds was employed to address each criterion.

15. Recommendations Better, more transparent data and processes urgently needed – Adding, modifying or eliminating benefits necessarily means adjusting budgets and payments Aligned agenda for greater public spending but also requires emphasis on greater effectiveness – Systems have limited focus on outcomes of care, few incentives to make connections 15

16. Source: Guanais and Macinko, Primary care and avoidable hospitalizations: Evidence from Brazil. Journal of Ambulatory Care Management 32 (2): 114-21, 2009 In Brazil, programs that increased primary health care access through community workers reduced avoidable hospitalizations for women Community Health Agents Program (PACS) and Family Health Program (PSF): approaches to improve primary health care access under government’s national health system In both programs, community health workers provide home visits PSF financing: – Municipal funds – Per capita payment from the federal government with financial incentives for higher levels of coverage 16

17. APPENDIX 17

18. Source: IADB Annual Reports Over time, the share of IDB lending to health and education has been low and relatively flat, and social investment has seen a huge decline since 2003 18 Percent Distribution of Social Sector Activities out of Total Loans and Guarantees, 2003-2012