Evaluating and improving health systems: achieving ...€¦ · A history of user charges:...
Transcript of Evaluating and improving health systems: achieving ...€¦ · A history of user charges:...
Evaluating and improving health systems:
achieving Universal Health Coverage in low- and middle-income
countries
Reinhard Busse, Prof. Dr. med. MPHDepartment of Health Care Management
Berlin University of Technology
(WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies
• What do we mean by coverage?
• What is “universal health coverage”?
• UHC and the broader Health System Performance Assessment
• Roads to achieve UHC – and the equity component
• Monitoring progress towards sustainable development
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>10 years ago: how to visualize coverage?
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The first Coverage Cube was born (still descriptive-analytical) …
universal
comprehensive
free at thepoint of service
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… picked up by WHO only a year later (and becoming normative) …
Note: since then, “universal” has been applied to all three dimensions …
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… and again in 2010 (being applied to UHC)
The goal of universal health coverage is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship.
It involves coverage with good health services (scope) as well as coverage with a form of financial risk protection (depth). A third feature is universality – coverage should be for everyone (breadth).
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What is univeral health coverage?
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WHO Health Report (2015) Tracking universal health coverage. First global monitoring report
Note: “quality” added = UHC
performance
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Health Systems Performance Assessment – my framework
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Access(ibility)Quality
(for those who receiveservices)
Outcomes=x
“Improved health”
“Responsiveness”/ “patient experience”
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Health Systems Performance Assessment – my framework
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Access(ibility)Quality
(for those who receiveservices)
x
=
Resources(money, personnell etc.)
Health system performance
Outcomes
Efficiency
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ROADS TO ACHIEVE UHC –AND THE EQUITY COMPONENT
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Evaluating and improving health systems for UHC
VHI*
SHI*
Not covered
“Coverage” by access to tax-financedprovision or insurance coverage
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VHI = voluntary private health insuranceSHI = social healthinsurance
POPULATION COVERAGECoverage by income in a typical middle-income country
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Result: Fragmented systems (uncovered not shown)
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Providersoften separate
for differentsegments
Population
GovernmentSickness funds
Private insurance+CBHI
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Evaluating and improving health systems for UHC
VHI
SHI
Not covered
“Coverage” by access to tax-financedprovision or insurance coverage
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Two ways to expand coverage:
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Need to extend coverage by (1) extending tax-financed coverage or …
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Need to extend coverage by (1) extending tax-financed coverage or …
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(2) extending the SHI system
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(2) extending the SHI system
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African countries with health coverage programs for …
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Contributory programs
Tax-financed programs Tax-financed programs
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SHI: looking at population coverage by income quintiles
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Vietnamas an exampleof missing middle
(early) Ghanaas an example of an
immature pro-rich system
Thailand without a missing middle (but rich partly excluded)
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Population coverage in low and middle-income countries (by income inquintile) – an example I
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Population coverage in low and middle-income countries (by income inquintile) – an example II
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Countries with betteraverages have (relatively)small inequities between
income groups …
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Population coverage in low and middle-income countries (by income inquintile) – an example III
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… while countries with worseaverages have large inequities
between income groups!
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Population coverage in low and middle-income countries (by income inquintile) – an example IV
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Differences for poor across countries are larger than for rich!
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SERVICE COVERAGEWhat is (not) covered?
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Basic Benefit Package (% of countries with no user fees for each intervention)
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Defining the benefit package – globally applicable
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“All” possiblehealth benefits
Covered benefit categories
Actual benefits
Representativeinstitutions, e.g.
Parliaments (Law)
Planning Bodies Coverage Commissions
using HTA
Criteria
• Economic crises in many developing countries in the 1980s
• Washington consensus
– Reduce public expenditures
– Introduce market based reforms
– Strongly promoted by World Bank and IMF, demanding structuraladjustment programs
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COST COVERAGEA history of user charges: background
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• Health care quality in public sector is bad
User charges can improve resource availability at providers(availabiltiy of medications, materials)
Can improve quality
Will increase public health service utilisation
• User charges can reduce costs and improve efficiency ofresource use
too much focus on hospital care
will free resources for basic services and for the poor whoshould be exempted
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World Bank arguments (back in the 1990s)
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1988
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But the assessment (and the advice) has changed:User fee policies around 2000 and their reforms in Africa
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41 countries
37 countries
4 countries
Afr
ican
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Countries Charging User Fees in Public Clinics and Hospitals (%)
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UHC AND WIDER HEALTH SYSTEM PERFORMANCE
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But good coverage ≠ good access
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Need (by socio-economic status, ethnicity/ migration status etc.)
x Quality = Outcomes
Unmetneed
Unmetneed
Realisedaccess
coverage (financial issues)
availability of care
waiting, acceptability etc.
Evaluating and improving health systems for UHC
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Services reported to be offered by facilities in 17 African countries, 2013-2017: even if covered, many services are not available!
availability of care
Source: SARA surveys on “readiness” (WHO Afro 2017)
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General service “readiness” in 17 African countries, 2013-2017:even if covered and available, quality & safety are inferior
x Quality (here: structure/ process)Source: SARA surveys on “readiness” (WHO Afro 2017)
e.g.Electricity
WaterPhone
Internet
e.g.Scale
ThermometerStethoscope
e.g.Haemoglobin
Malaria
• SDG 3.8: Achieve UHC, including financial risk protection, access to quality essential health-care services and access to […] essential medicinces and vaccines for all
• Indicators
3.8.1: Coverage of essential health services
3.8.2: Financial protection when using health services
(originally: number of people covered by health insurance or a public health system per 1,000 population)
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Monitoring Achievement of UHC as part of SDGs
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• Ideally:
– Measure effective coverage (proportion of people in need of services who receive services of sufficient quality to obtain potential health gains)
– Include range of services (promotion, prevention, curative services, rehabilitation, palliation)
– Cover main health areas (Reproductive/ maternal/ neonatal/ child health, infectious and non-communicable diseases, injuries)
– Disaggregate index for inequality dimensions
De facto a measure of coverage, availability and quality
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Measuring coverage of essential health services
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Selection based on:
• Relevance (disease burden, available interventions)
• Measurable coverage andclear target
• Data availability acrosscountries (also for equityanalysis)
• Easy to communicate
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Data on inpatientand outpatientservice use is
unavailable for LMIC
Data on coveragewith diabetes
care unvailable
Calculating the UHC service coverage index
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The result: but where is the problem in low-scoring counries?
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UHC service coverage by region and subindices
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• Catastrophic spending on health SDG indicator 3.8.2
– Proportion of the population with large household expenditure on health as a share of total household expenditure or income (e.g. greater than 10% or 25%)
• Impoverishing spending on health related to SDG 1.1.1
– Out-of-pocket spending pushes households below the poverty line (here: $1.90 or $3.10).
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Measuring financial protection
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Catastrophic health spending worldwide
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Impoverishment due to out-of-pocket spending
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THE CONTRIBUTION OFUNIVERSAL HEALTH CARE TOSUSTAINABLE DEVELOPMENT
At least as important:
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For individuals: poverty in informal sector
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For society: economic growth
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• The understanding of UHC has become broader, possibly making it more difficult to understand
• Important for both researchers and policy-makers alike to understand its dimensions: population, service + cost coverage (the “cube”) + availability + quality “effective coverage” (as part of wider performance)
• To achieve UHC, (1) indicators to measure each dimension are required, (2) data have to be collected, (3) the situation has to be critically assessed and compared, (4) good practice based on evidence from elsewhere should be implemented and (5) progress has to be monitored and policies adapted accordingly
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Conclusions/ take-home messages
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