1. Best Practices in Healthcare Financing: Sri Lanka Case Ravi P. Rannan-Eliya ECOSOC Annual Ministerial Review – Regional Ministerial Meeting on Financing Strategies for Health Care 16-18 March, 2009 Colombo, Sri Lanka

2. 1 WB Good Practices in Health Financing

3. Low healthcare spender 2

4. ... yet good health at low cost 3

5. 4 Good financial protection

6. ... despite significant out-of- pocket spending 5

7. Formative origins in 1930s Democracy in 1931 –Made government accountable to people –Income tax introduced –Free education Autonomy from foreign influence –Self-rule with freedom to find our own way Adequate resources –Relatively good tax base Economic crisis and epidemics –Impact of 1930s Global recession and 1934 Great Malaria Epidemic 6

8. Consequences High priority given to risk protection –High allocation of budget to inpatient care and hospitals (>75%) Emphasis on physical access over consumer quality –Extensive network of rural facilities –Pro-poor government spending Removal of financial barriers –Abolition of user fees (1951) 7

9. Increase in public provision 8

10. ... despite falling health budgets 9 % GDP

11. Made possible by 2-3% annual increases in efficiency 10

12. Yet Sri Lanka is not a NHS system 11

13. 12 but a third model Developing countries cannot afford UK NHS (“Beveridge”) model –Cost of government financing free care for all: 5-8% of GDP –Actual government budgets: 2-3% of GDP So only able to pay for 40-60% of overall needs through public financing –Typical outcome is that limited public services are captured mostly by rich, leaving poor without services –Rationing through spatial barriers, or informal costs Sri Lanka has solved this by successful mix of public and private financing and provision –Public services universal but used more by poor –With public spending focusing on insurance function

14. Sri Lanka’s public-private mix 13

15. 14 With self-selection of rich into private sector Use of public and private inpatient services by income quintiles

16. Key Messages Accountability to people is critical Government must provide insurance through hospital care Improving efficiency is critical for expanding coverage Never give up on public sector Manage the financing gap by prudent use of voluntary private care 15