\

Workshop on Dissemination of Study Results: The Financial Burden

of Health Payments

Towards universal coverage

h. Reduce cost sharing and fees :

Population: who is covered?

Financial protection: what do

Include people have other to pay out-

services of-pocket?

23-24 March 2011 Manila, Philippines

(mf~\ World Health ~~tl Organization _.,~

Western Pacific Region

WPR/DHS/HCF(01)/2011

Report series number: RS/2011/GE/13(PHL)

REPORT

WORKSHOP ON DISSEMINATION OF STUDY RESULTS:

THE FINANCIAL BURDEN OF HEALTH PAYMENTS

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 23-24 March 2011

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western pacific

Manila, Philippines April2011

WHOIWPRO LIBRAR~ M A NTLA. PHTL TP'PtN"ES

2 7 St? ~01\

English Only

NOTE

The views expressed in this report are those of the participants in the Workshop on Dissemination of Study Results: the Financial Burden of Health Payments and do not necessarily reflect the policies of the world health organization.

This report has been prepared by the ~~rld Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for those who participated in the Workshop on Dissemination of Study Results: the Financial Burden of Health Payments from 23 to 24 March 2011 in Manila, Philippines.

CONTENTS

SUMMARY

1. INTRODUCTION ..... .. ... ................... ......................... ................. ....... .. ...... ... ....... ........... 1

1.1 Objectives ............... ............ ................ ...... ....... .. ..................... ...................... ....... .. ! 1.2 Opening remarks .... .... .. ... .................... ..... .... .. ......... .. ..... ... ....... ....... ....................... 2 1.3 Appointment of the Chairperson .... .. ....... ............. ......... ........ ... ..................... .... ..... .. 2

2. PROCEEDINGS ......... .... ....... ... ..... ... .............. .............. ..... ...... ............ .... ............. ..... .. .. . 2

2.1 Setting the scene (global overview, fiscal space, research methodologies) ........... .... 2 2.2 Country study results .............................................................................................. 3 2.3 Country policy briefs ................................ ........... .......... ..................................... .... 4 2.4 Regional policybrief ............................................................................................ .. 5 2.5 Next Steps ........................................................................................................... .. . 5

3. CONCLUSIONS ..................... .... .. ........ ..... .. ................... ..... .. .. ...... ...... .. ..... .. ............. ... .. 6

ANNEXES:

ANNEX 1 - AGENDA ANNEX 2 - TIMET ABLE ANNEX 3 -LIST OF PARTICIPANTS ANNEX 4 - PRESENTATIONS

Keywords:

Health care costs I Health expenditures I Delivery of health care-- economics

SUMMARY

The Workshop on Dissemination of Study Results: the Financial Burden of Health Payments was held in Manila from 23 to 24 March 2011.

The workshop was attended by health financing experts and policy makers from six Western Pacific Region countries (Cambodia, China, Lao People's Democratic Republic, Mongolia, the Philippines and VietNam). It was also attended by WHO health financing experts and the following international development partners: Asian Development Bank (ADB), Australian Agency for International Development (AusAID), Equity in Asia-Pacific Health Systems (EQUIT AP), Deutsche Gesellschaft fiir Internationale Zusammenarbeit Gmbh (GIZ), National Health Insurance Corporation (NHIC), the Republic ofKorea, and the World Bank.

The objectives of the meeting were:

(1) to discuss the health financing policy implications of the results from country studies in Cambodia, China, the Lao People's Democratic Republic, Mongolia, the Philippines and VietNam;

(2) to discuss country-specific policy briefs that are being developed in China, the Lao People's Democratic Republic, Mongolia, the Philippines and VietNam; and

(3) to agree with countries and other development partners on future collaboration and WHO support on monitoring the financial burden of health payments on a regular basis, and on reviewing health financing policies.

Each country team presented the results of the studies and related policy briefs. These were discussed in plenary sessions and small working groups. WHO staff presented health financing strategies for universal coverage with an emphasis on the World Health Report 2010 and Health Financing Strategy for the Asia Pacific Region (2010-2015). The research method to analyse the financial burden of health payments used for the country studies was presented. EQUITAP presented an overview of the cross-country comparisons of the health financing situation in Asia Pacific region.

Outputs of the meeting included the following:

Objective 1 - Study results and associated health financing policy implications from each of the countries were presented and discussed.

Objective 2- Draft country-specific policy briefs developed by each of the country teams were discussed.

Objective 3 - Future collaboration of WHO with the countries and other development partners on monitoring the fmancial burden of health payments on a regular basis, and on reviewing health financing policies was discussed.

1. INTRODUCTION

The workshop on Dissemination of Study Results: the Financial Burden of Health Payments was held in Manila from 23 to 24 March 2011.

The workshop was attended by health financing experts and policy makers from six Western Pacific Region countries (Cambodia, China, Lao People's Democratic Republic, Mongolia, the Philippines and VietNam). It was also attended by WHO health financing experts and the following international development partners: Asian Development Bank (ADB), Australian Agency for International Development (AusAID), Equity in Asia-Pacific Health Systems (EQUITAP), Deutsche Gesellschaft fiir Internationale Zusammenarbeit Gmbh (GIZ), National Health Insurance Corporation (NHIC), the Republic of Korea, and the World Bank.

Excessive out-of-pocket payments (OOP) for medicines and health services are known to discourage people from seeking care. Furthermore, for households who do receive treatment, there is a risk of catastrophic health expenditures or even impoverishment because of the cost of care. The World Health Report 2010 recommends various prepayment mechanisms to help alleviate the financial burden of health payments. These recommendations are consistent with the Health Financing Strategy for the Asia Pacific Region (2010-2015) where high OOP payments are a particular concern. Within this regional strategy framework, WHO provided training to teams from China, Lao People's Democratic Republic, Mongolia, the Philippines and VietNam in June 2010 in the WHO methodology for analysing the financial burden of health payments. The trained teams each conducted a study to analyse the financial burden of health payments in their country and developed health financing policy briefs to reduce OOP payments.

This workshop was convened to share and discuss the country specific research fmdings and policy briefs.

1.1 Objectives

(1) to discuss the health financing policy implications of the results from country studies in Cambodia, China, Lao People's Democratic Republic, Mongolia, the Philippines and VietNam;

(2) to discuss country-specific policy briefs that are being developed in China, Lao People's Democratic Republic, Mongolia, the Philippines and VietNam; and

(3) to agree with countries and other development partners on future collaboration and WHO support on monitoring the financial burden of health payments on a regular basis, and on reviewing health financing policies.

- 2 -

1.2 Opening remarks

Dr Henk Bekedam, Director, Health Sector Development and Officer-in-Charge, WHO Western Pacific Regional Office, delivered the opening remarks. Countries in the Western Pacific Region have had a good level of economic development, but millions still suffer from ill health because they cannot get the health care they need or because paying for health care devastates their livelihood and pushes them into poverty. This is of particular concern in the Western Pacific Region, where out-of-pocket payments for medicines and health services are often excessive. A better understanding on households affected by health payments is needed. But evidence alone is not enough. The next step is how evidence can be used to influence policy and bring partners together to support countries. Better partnerships between country policy-makers and developmental partners are essential to make headway on the path to universal coverage.

1.3 Appointment of the Chairperson

Dr V easnakiry Lo, from Ministry of Health, Cambodia was appointed the Chairperson of the workshop.

2. PROCEEDINGS

2.1 Setting the scene (global overview, fiscal space, research methodologies)

A short overview of the workshop was presented reminding participants of the three main objectives and the workshop timetable.

Dr Dorjsuren Bayarsaikhan, Team Leader for Health Care Financing, WHO Western Pacific Regional Office, presented the main objectives of Universal coverage as outlined in the World Health Report 2010 and the Health Financing Strategy for the Asia Pacific Region (2010-2015). Global evidence indicates huge inequalities in availability and access to health services. Health spending by governments in many countries is inadequate in the Western Pacific Region. Consequently there is often over reliance on direct OOP to finance health care. This is of a concern because high OOP are associated with catastrophic payments and impoverishment. Causes of inefficiency also were outlined including inappropriate use of medicines and services, inappropriate mix of health workers and medical errors. He emphasized the need to increase government expenditure for health, ways to reduce out of pocket payments and efficient use of available resources to provide access to quality health services to all.

Dr Chris James, Technical Officer, Macroeconomics and Health, WHO Western Pacific Regional Office, presented on fiscal space for health, that is to what extent governments can feasibly increase spending on health. He first outlined the main options for governments and then illustrated the varying degree of fiscal space for health in the Asia-Pacific Region. Low- and middle-income Asian countries were shown to have substantial fiscal space for health in contrast to Pacific islands and high income countries. He also briefed on methods to assess expected resources available for health through the WHO simulation tool "Macro Health."

- 3 -

Dr Ke Xu, Health Economist, WHO Headquarters, gave an overview of the WHO methodology for analysing the financial burden of health payments used for the studies conducted in the six countries over the last one year. The focus of the methodology was to understand the utilization patterns of health services and household expenditures on health. She stressed how such evidence can be used to facilitate country policy dialogue regarding the transition to universal coverage.

Dr Ravindra Prasan Rannan-Eliya, Director of Institute for Health Policy, Sri Lanka, gave a briefing on the EQUITAP project, a collaborative etiort of research teams in Asia and Europe. Evidence from EQUIT AP shows wide disparity in catastrophic health spending in the Asia Pacific Region. He opined comparative analysis of health systems performance can be highly effective in supporting and influencing policy change.

2.2 Country study results

The following participants presented the results of their research:

Philippines: Dr Rouselle F. Lavado Philippine Institute for Development Studies

Mongolia: Dr Chimeddagva Dashzeveg Economic Advisor to the Minister of Health

China: Dr Keqin Rao, Chinese Medical Association

Cambodia: Dr Piya Hanvoravongchai London School of Hygiene and Tropical Medicine

Lao PDR: Dr Manithong Vonglorkham National Institute of Public Health, Ministry of Health

VietNam: Dr Hoang Van Minh, Hanoi Medical University

The following is a summary of the key research findings.

Low utilization of health services

The utilization of health services was low in all the countries. For example, in Lao People's Democratic Republic, the utilization rate was only 2% while the reported need for care was 8%. In China, among the households reporting illness, 11% did not seek medical consultation and 21% did not seek inpatient care. 70 % of them cited inability to pay as the main reason.

Further in some countries, disaggregated data shows a significant variation in access to health care across population groups. Utilization rates in the poorer quintiles were typically lower than the richer quintiles. For example, in Cambodia, only 28% of the poorest sought care when ill (the respective figure for the highest income quintile was 10%). This reflects that poorer households have a lower ability to pay for health services.

- 4 -

Financial burden: catastrophic health expenditures and impoverishment

Out of pocket payments for health as a share of total expenditure on health are lowest in Mongolia (11.5%) and as high as 61% in Cambodia and Lao People's Democratic Republic. Households suffered catastrophic health expenditure in all the countries. Preliminary findings suggest 14% of the households in China, 5.5% in VietNam, 4.1% in Cambodia, and 3.8% in Mongolia suffered catastrophic health expenditures; 2.2% households in Lao People's Democratic Republic and 1.2% in the Philippines were affected. Low catastrophic rates in Lao People's Democratic Republic and the Philippines are likely to reflect low utilization rates. Catastrophic health expenditure was observed among all quintiles of population. It was high among households with children under the age of five and elderly aged above 60 years in Cambodia and China. About (6.8%) households in China and (6.1%) in Cambodia were impoverished due to expenditures on health. The percentage of impoverished households is 3.5% in VietNam, 1.8% in Mongolia, 1% in the Philippines, and 0.7% in Lao People's Democratic Republic, according to the latest available data.

2.3 Country policy briefs

Following in-depth group work, country delegations presented policy briefs:

Philippines:

Mongolia:

China:

Cambodia:

Lao PDR:

VietNam:

Dr Virginia Ala, Department of Health

Dr Erkhembulgan Purevdorj Strategic Policy and Planning Department, Ministry of Health

Dr Qunhong Wu Harbin Medical University, School of Health Management

Dr V easnakiry Lo Ministry of Health

Dr Bouaphat Phonvisay Ministry of Health

Ms Nguyen Thi Kim Phuong WHO VietNam Country

The presentations summarized the key findings and then outlined the main policy implications given their country context. Some common elements are highlighted below.

Raising resources for health

The necessity of raising resources for health to achieve universal coverage was emphasized. Increasing the share of government spending on health was recommended. Some countries expect increase in government budgets for health from revenues of the domestic oil and mining industry. Implementing strict tax/premium collection mechanisms, raising revenues from taxes on alcohol, tobacco and channelling external aid for health through sector wide approach were also proposed.

- 5 -

Risk pooling

Currently, all the countries have some forms of social health protection schemes to reduce the financial burden of health payments. However, in Cambodia and Lao People's Democratic Republic, these schemes are highly fragmented and their coverage is low. They proposed to strengthen risk pooling by merging existing schemes including the integration of community based health insurance schemes and health equity funds. China, Mongolia, the Philippines, and have higher population coverage, but certain population groups are still not covered. They proposed expanding risk pooling base to cover dependents of workers, migrant workers, informal sector, and indigenous groups. Re­evaluating the benefit packages was also recommended as currently the reimbursement rates are low. Parallel to strengthening risk pooling, countries also proposed the importance of supply side investments to increase access to health services in the rural areas and improving quality of care in health facilities to increase utilization of services.

Promote efficie~cy in purchasing of services

A need for more critical assessment of benefit package entitlements was proposed. Existing benefit packages though were broadly defined; in reality the actual reimbursements were lower. Shifting provider payment mechanisms from fee for service to better alternatives (capitation, case mix or diagnosis related groups) has been proposed to increase efficiency and value for money. The importance of regulating quality of care and purchasing services only from accredited providers was also emphasized.

2.4 Regional policy brief

An outline for a regional policy brief was presented by Dr Chris James. Its aim is to complement country policy briefs by providing a regional picture of reliance on high OOP payments and policy recommendations by country groupings. These would build on findings from the World Health Report 2010 and linked to the country specific policy briefs.

2.5 Next steps

An open session on next steps was chaired by Dr H. Bekedam. Each country discussed issues relating to current reforms in health financing in their country, existing collaborations with developmental partners and ways to take the analytical work on health financing forward.

(1) The regional policy brief, country study results and policy briefs would be used to support policy decisions in the countries on their path to universal coverage.

(2) The analytical work by the research teams would be continued to monitor the financial burden of payments in the countries to support the health financing strategies.

(3) The developmental partners attending the workshop agreed to collaborate when working at country level in supporting the country on their path to universal coverage.

Slides from all the presentations are shown in Annex 4.

- 6 -

3. CONCLUSIONS

The Workshop on Dissemination of Study Results: the Financial Burden of Health Payments accomplished its three objectives.

Outputs of the meeting included the following:

Objective 1 -

Objective 2-

Objective 3

Study results and associated health financing policy implications from each of the countries were presented and discussed.

Draft country-specific policy briefs developed by each of the country teams were discussed.

Future collaboration of WHO with the countries and other development partners on monitoring the financial burden of health payments on a regular basis, and on reviewing health financing policies was discussed.

WORKSHOP ON DISSEMINATION OF STUDY RESULTS: THE FINANCIAL BURDEN OF HEALTH PAYMENTS

MANILA, PHILIPPINES 23-24 MARCH 2011

AGENDA

1. Opening session

2. Workshop overview

3. Health financing and universal coverage

4. The WHO methodology for analyzing the fmancial burden of health payments

5. Introduction to the EQUITAP project

6. Country study results

7. Country policy briefs

8. Regional policy brief

9. Next steps

10. Closing

ANNEX I

TIME

07:30 08:00

08:20 08:30

09:15

09:45

10:15

10:30 11:00 11:30 12:00 13:00

14:00 14:30 15:00

15:15 15:45 17:00

19:00

ANNEX2

WORKSHOP ON DISSEMINATION OF STUDY RESULTS: THE FINANCIAL BURDEN OF HEALTH PAYMENTS 23-24 March 2011. Manila, Philippines

TIMETABLE

23 MARCH (Wed) TIME 24 MARCH (Thu)

Registration I. Opening session 08:00 Summary of day 1 & Introduction to day 2 (K.Xu)

0 Speech of the Regional Director 08:20 7. Country policy briefs (group work): country-specific discussions . Introduction of participants Introduction: 0 Election of Chairperson . Is the country and health financing context succinctly summarized?

2. Workshop overview (C.James) Study summary: 3. Health financing and universal coverage . Does the policy brief highlight key results from the study?

0 The World Health Report 2010 and Health Financing Strategy for Policy implications: the Asia Pacific Region 2010-2015 (D.Bayarsaikhan) 0 Are viable policy options offered for improving financial protection . Fiscal space for health: options for raising sufficient funds again~t the costs of care? (C.James) . Are broader policy implications assessed?

4. The WHO methodology for analyzing the financial burden of health 0 Are options for working with partners detailed? payments (K.Xu) 5. Introduction to the EQUITAP project (R.R-Eliya)

COFFEE BREAK (including Group Photo) 10:00 COFFEE BREAK 6. Country study results 10:15 Country policy briefs: presentations by China, Mongolia, Philippines

0 Philippines (R.Lavado) 10:45 Discussion 1 (China, Mongolia, Philippines) 0 Mongolia (D.Chimeddagva) 0 China (K.Rao I Q.Wu) 11:30 Country policy briefs: presentations by Cambodia, Lao PDR, VietNam

Discussion 1 (China, Mongolia, Philippines) 12:00 Discussion 2 (Cambodia, Lao PDR, VietNam) LUNCH BREAK 13:00 LUNCH BREAK

Country study results (continued) 0 Cambodia (P.Hanvoravongchai I L.Veasnakiry) 14:00 8. Regional policy brief (C.James I K.Xu) . Lao PDR (M.Vonglokham I B. Phonvisay)

COFFEE BREAK 15:00 COFFEE BREAK Country study results (continued) . VietNam (V.M.Hoang) 15:15 9. Next steps (H.Bekedam)

Discussion 2 (Cambodia, Lao PDR, VietNam) o Analytical work on monitoring the financial burden of payments End of Day 1 • Other analytical work (including available approaches/tools)

o Support to health financing strategies, regulations, etc Dinner hosted by Dr H.Bekedam o Partnerships

16:30 10. Closing

WORKSHOP ON DISSEMINATION OF STUDY RESULTS: THE FINANCIAL BURDEN OF HEALTH PAYMENTS

MANILA, PHILIPPINES 23-24 MARCH 2011

ANNEX3

LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS/REPRESENTATIVES AND SECRETARIAT

CAMBODIA

CHINA

LAO PEOPLE'S DEMOCRATIC REPUBLIC

MONGOLIA

1. PARTICIPANTS

Dr Vichea Ravouth L Y, Vice Chief, Bureau of Planning and Health Sector Reform, Department of Planning and Health Information, Ministry of Health

No. 151-153 Avenue Kampuchea Krom, Phnom Penh Email: vichealy@yahoo.com; Tel no. 855-12687724

Ms Nary SO, Chief of Financial Planning Office, Department of Budget and Finance, Ministry of Health, No. 151-153 Avenue, Khan 7 Makara, Phnom Penh,; Email: narysomoh@yahoo.com; Tel no. 855-23881408

Dr Xiaoxiao TIAN, Assistant Researcher, Ministry of Health No. 1 Xi Zhi Men Wai Nan Road, Xicheng District, Beijing 100044 Email: maggietian@163.com; Tel no. 8610-68792814

Dr Ren LU; Department of Planning and Finance; Ministry of Health No. 1 Xi Zhi Men Wai Nan Lu; Beijing 100044 Email: renlu@moh.gov.cn; Tel no. 8610-68792891

Dr Suphab PANYAKEO, Hospital Financial Information Management, System Planning and Finance Department, Ministry of Health, Vientiane, Email: dtatamone@yahoo.co.nz; Tel no. 85620-55335130

Dr Manithong VONGLOKHAM, Technical Staff, c/o Ministry of Health, Kaognot Village, Samsenthai Road, Sisattanak District, Vientiane Email: manithongvlk@yahoo.com; Tel no. 85620-250670

Dr Erkhembulgan PUREVDORJ, Deputy Director, Strategic Policy and Planning Department, Ministry of Health, Olympic Street 2, Ulaanbaatar 48; Email: erkhembulgan@moh.mn; Tel no. 976-266178

Mr Otgonbaatar DONDONKHUU , Deputy Director, Finance and Investment, Department, Ministry of Health, Government Building-8, Olympic Street-2, Ulaanbaatar 210648; Email: aotgoo2001@yahoo.com; Tel no. 976-8810012; 975-51264269

Annex 3

PHILIPPINES

VIETNAM, SOCIALIST REPUBLIC OF

Dr Israel P ARGAS, Senior Manager, Benefits Development and Research Department, Philippine Health Insurance Corporation, Room 1210, 12th Floor, City State Center, 709 Shaw Boulevard, Pasig City, Philippines Email: pargasi@philhealth.gov.ph; Tel no. 632 6381682

Dr Ma. Virginia ALA, Director, Bureau of Health Policy Development and Planning, Department of Health, Rizal Avenue, San Lazaro Compound, Sta Cruz, Manila, Philippines, Email: marvie _ala@yahoo.com; Tel no. 632-7115377

Dr TONG Thi Song Huong, Director, Health Insurance Department, Ministry of Health, 138A Giang Vo Street, HaNoi Email: huongbhyt@yahoo.com; Tel no. 844 0913252280

2. TEMPORARY ADVISERS

Dr Dashzeveg CHIMEDDAGV A, Economic Advisor to the Minister of Health, Ministry of Health, Olympic street-2, Government Building VIII, Ulaanbaatar-48, Mongolia, E-mail: chimmeddagva@grnail.com; Tel no. 976-99116661

Dr Piya HANVORA VONGCHAI, Lecturer, London School of Hygiene and Tropical Medicine, Keppel Street, London WClE 7HT, United Kingdom E-mail: piya@post.harvard.edu; Tel no. 440-20-7636 8636

Dr Rouselle LAV ADO, . Senior Research Fellow, Philippine Institute for Development Studies (PIDS), NEDA sa Makati Building, 106 Amorsolo St. Legaspi Village, Makati City 1229, Philippines E-mail: rlavado@mail.pids.gov.ph; Tel no. 632-8939585 Ext 3112

Dr Bouaphat PHONVISAY, Acting Chief of Health Insurance Department of Planning and Finance, Health Insurance Ministry of Health, Vientiane, Lao People's Democratic E-mail: Boua_phat@yahoo.com; Tel no. 856-20-2864195

Division, Division, Republic

Dr Ravindra Prasan RANNAN-ELIY A, Director & Fellow, Institute for Health Policy, 72 Park Street, Colombo 2, Sri Lanka, E-mail: ravi@ihp.lk; Tel no. 9411-2314041

Dr Van Minh HOANG, Department of Health Economics, Hanoi Medical University, Health Economics Department, No 1 - Ton That Tung - Dong Da, Hanoi, VietNam, Email: hvminh71@yahoo.com; Tel no.: 844.38523798

DEPARTMENT HEALTH (DOH) PHILIPPINES

ASIAN DEVELOPMENT BANK(ADB)

AUSTRALIA AGENCY FOR INTERNATIONAL DEVELOPMENT (AusAID)

DEUTSCHE GESELLSCHAFT FUR INTERN A TIONALE ZUSAMMEN­ARBEIT (GIZ)

NATIONAL HEALTH INSURANCE CORPORATION (NHIC)

Annex 3

Dr Veasnakiry LO, Director, Department of Planning and Health Information, Ministry of Health, 151-153, Kampuchea Krom (St. 128), Phnom Penh, Cambodia; Email: veasnakiry@online.com.kh; Tel. no. 855 12 8210595

Dr Keqin RAO, Chinese Medical Association, No.42 Dongsi West Avenue Beijing 100710, China, Email: raokq@moh.gov.cn

Dr Qunhong WU, Professor, Deputy Dean, Health Management College, Harbin Medical University, School of Health Management, 157 Bapkoam Road, Nangan District, Harbin, China, Email: wqh@ems.hrbmu.edu.cn; Tel no. 8610-4518702851; Fax: no. 8610-4518702853

4. OBSERVERS/REPRESENTATIVES

Dr Ma Rosario VERGEIRE, Medical Officer, Bureau of Health Policy OF Development and Planning, Department of Health, Rizal A venue, San Lazaro Compound, Sta Cruz, Manila, Philippines Email: rosettovergeire@yahoo.com; Tel no. 632-7115377

Mr Claude BODART; Principal Health Specialist; Urban and Social Sectors Division; Asian Development Bank; 6 ADB Avenue, Mandaluyong City 1550 Metro Manila, Philippines; Email: cbodart@adb.org, Tel no. 632-6325322

Mr Benedict DAVID, Principal Health Adviser, Australian Agency for International Development, 255 London Circuit, GPO Box 887, Canberra ACT 2601 , Australia, Email: benedict.david@ausaid.com.au Tel no. 612 62064000

Dr Jose CARDONA, Deutsche Gesellschaft fiir Internationale Zusammenarbeit Gmbh, Social Health Insurance Component Manager Microinsurance Innovations Program for Social Security (MIPSS) Component 3 Office, Room 1097 Citystate Centre Building 709 Shaw Boulevard, Pasig City, Metro Manila, Philippines Email: jose.cardona@giz.de; Tel no. 632-6361387

Mr Jong Hyun JO, Deputy Director, Health Insurance Policy Research Institute National Health Insurance Corporation, 168-9 Yeomi-dong, Mapo-gu, Seoul 121-479, Republic of Korea. Tel no. 822-32709835

Mr Choon Sik PARK, Deputy Director, Health Insurance Policy Research Institute National Health Insurance Corporation, 168-9 Yeomi-dong, Mapo-gu, Seoull21-479, Republic of Korea, Tel no. 822-32709835

Annex 3

WORLD BANK

PHILIPPINE INSTITUTE FOR DEVELOPMENT STUDIES (PIDS)

Mr Jin Eok KIM, Manager, Department of Finance and Management, National Health Insurance Corporation, 168-9 Yeomi-dong, Mapo-gu Seoul121-479, Republic ofKorea; Tel no. 822-32709106

Mr Won WHANG, Manager, Health Insurance Policy Research Institute National Health Insurance Corporation, 168-9 Yeomi-dong, Mapo-gu, Seoul 121-479, Republic of Korea, Email: won09@nhic.or.kr; wineth@hanmail.net; Tel no. 822-32709836

Dr Eduardo BANZON, Senior Health Specialist, The World Bank, 23/F, The Taipan Place Building, F Ortigas Jr Road, Emerald Avenue Ortigas Center, Pasig City 1605, Metro Manila, Philippines Email: ebanzon@worldbank.org; Tel. no. 632-6375855 or 9173000

Mr Valerie T. ULEP, Supervising Research Specialist, Philippine Institute for Development Studies, NEDA sa Makati Building, 106 Amorsolo St., Legaspi Village, Makati City 1229, Philippines, Email: vulep@pids.gov.ph; Tel no. 632-8939586 ext 311

5. SECRETARIAT

WHO WESTERN Dr Henk BEKEDAM, Director, Health Sector Development, WHO Western PACIFIC REGIONAL Pacific Regional Office, U.N. Avenue, 1000 Manila, Philippines OFFICE Email: bekedamh@wpro.who.int; Tel. no. 632-5289802; Fax no. 632-5211036

Dr Dorjsuren BAY ARSAIKHAN, Team Leader in Health Care Financing, Division of Health Sector Development, The World Health Organization Regional Office for the Western Pacific, U.N. Avenue, 1000 Manila, Philippines Email: bayarsaikhand@wpro.who.int; Tel. no. 632-5289808

Dr Chris JAMES, Technical Officer - Macroeconomics and Health Division of Health Sector Development, The World Health Organization Regional Office for the Western Pacific, U.N. Avenue 1000 Manila, Philippines, Email: jamesc@wpro.who.int; Tel no. 632-5289849

Dr Benjamin LANE, Technical Officer, Office of the WHO Representative in Cambodia, No. 177-179 comer Streets Pasteur (51) and 254, Sangkat Chak Tomok, Khan Daun Penh, Phnom Penh, Cambodia Email: laneb@cam.wpro.who.int; Tel. no. 855-232810

Dr Valeria de OLIVEIRA-CRUZ, Technical Officer in Health Financing and Health Systems Development, Office of the WHO Representative in Lao PDR, 125 Saphanthong Road, Unit 5, Ban Saphanthongtai, Sisattanak District, Vientiane, Lao People's Democratic Republic Email: Deoliveiracruzv@wpro.who.int; Tel no. 85621-353 902/3/4

WHO HEADQUARTERS

Annex 3

Ms Lucille NIEVERA, National Tuberculosis Centre Building, Office of the WHO Representative in the Philippines, Department of Health, Rizal Avenue Sta. Cruz, Manila, Philippines, Email; Tel no. 632-743-8301 Ext 1931

Ground Floor, Bldg. 3 comer Tayuman Street, nieveral@phl. wpro. who.int;

Ms Thi Kim Phuong NGUYEN, National Programme Officer - Health Financing, Office of the WHO Representative in Viet Nam 63 Tran Hung Dao Street, Hoan Kiem District, HaNoi Socialist Republic of Viet Nam; Email: phuong@vtn.wpro.who.int Tel. no. 844-9433734

Ms Erdenechimeg ENKHEE, National Programme Officer, Office of the WHO Representative in Mongolia, Post Box- 663, Ulaanbaatar-13, Mongolia, Email: enkheee@mog.wpro.who.int; Tel no. 97611-327870

Dr Ke XU, Health Economics/Health Financing Policy, Health Systems Financing, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland; Email: xuk@who.int; Tel. no. 4122-7912111

Dissemination workshop of study results: the financial burden of health payments

23-24 March 2011 Manila, Philippines

WORKSHOP OVERVIEW

OBJECTIVES

To discuss country study results and their policy implications from studies in Cambodia, China, Lao PDR, Mongolia, the Philippines and Viet Nam To discuss and further develop country-specific policy briefs

ANNEX4

To discuss with countries and other development partners on future collaboration and support

Dissemination workshop of study results: the financial burden of health payments

23-24 March 2011 Manila, Philippines

WORKSHOP OVERVIEW

CONTENT

• Setting the scene

• Country study results

• Country policy briefs • Regional policy brief

• Next steps I partnerships

Annex 4

Workshop on Dissemination of Study Results: The Financial Burden of Health Payments,

Manila, 23-24 March 2011

The World Health Report 2010 and Health Financing Strategy for the Asia and Pacific

Region 2010-2015

D.Bayarsaikhan, Team Leader~ Health Care Financing, WPRO

~World Health Organization

Universal coverage • Ali people have timely access to needed health services at

affordable cost. • Timely access is an issue if health services are not available or

health service providers are inadequately funded through existing health financing systems.

• Access to health services Is still an issue itthey require direct payments from patients. Many low Income households can not afford the111 or impoverished because of their use of health services.

• Unlversil l coverage broadens policy discussions on health service covt;!rage quality, availability, p<;lpulation coverage, access and health care·ftnanclng In terms of adeq.uacy, equity, efficiency and financial rfsk protection.

• Health service coverage likely varies across and within countries . Globallv., lt is available on ly forfew interventions such as immunization a nd skilled birth attendance.

1"000 900 800 700 600 500 400 300 200 100

0

MMR and SBA coverage

.-

, ~-- ,'I ..n _...-q LAO CAM PNG PHI... VTN MOG CHN

§

8

8

~

R

Background • Sep 2009-the 601h RCM endorsed the

Health Financing Strategy.

March 201 0-the Strategy is officially launched in the region and followed by countries. It is available. in 6 languages.

Nov 2010-the World Health Report is published and launched in Berlin.

Dec 2010-Jan 2011-the WHR was launched in CAM, CHN, LAO, MOG, PHL and VTN.

Percentage of births attended by skilled health worker

Q1, Q5 and Average- 22

. i !11 l 1·

0

'To~----~,o~----~~~------~~-------4~D-------.~o-

I ~ ; ~.!.,•.a• I Soun:.e: La teal. •v•ll•bla OHS for -ch couotry (excl. CIS caun""'•l

Population coverage

Health insurance coverage, 0/o

Soun::1~ H~ financing rafom~•: Challenges In achiiiiYing unlvtn-' COienr.ge. Health In SoulhMISI A•!. 6, L.anc:ot Mries, 2011 AdJUSted eccoiding to 1M. Aquino Health Agend.:: Adii&Ying UnNereal Health Cara frK All Filipino:s, Cec 2010

Adequacy and efficiency

• Some governments spend on health inadequately relative to their national income.

-The WHO Commission on Macroeconomics and Health- US$ 34 per pe'rson to deliver basic health services (2001).

-The WHO High-level Taskforce on Innovative International Financing for Health Systems-US$ 60 per person to ariain MOGs {2009)

• Available and limited financial resources are often spent inappropriately. The WHR 2010 estimates that 20%-40% of current health spending is wasted through inefficiency.

Millions of people suffer when they use health services

EMO

~ o impo\.IE!rishment AFO • catastrophic ev• I--t I ....

; AMR - i

"""" •v 6 0 00

Number of people (million)

WHR 2010: Each year, 150 million people globally suffer financial cZitastrophe. Similarly, 100 million people are pushed into poverty because of direct OOP.

EQUITAP: In the Asia-Pacific region so million people experience financial catastrophe and 50 million impoverish due to health payments.

Towards universal coverage

h Rodycs cost shar1ng and fees:

) ·-·--··· . /

....-E~:t!nd tc

4·~~~·~;~~

PDpu.Jction: who iii covf!red?

Annex 4

Government and private health spending,%

8 __;c_ """f' _l'~['":''"·,.;o,C'"c,. =-;,.,-··· .. - ···"1 7 _;!_

~··...-..;~ .. ' - "l''< !!!;;-_ - ! . -"'- ·"'-·

~ 1 ~,- ~, ·- JQ<~ A}' . ..... -5 - -~ -~ ~. }

I 4 . ;.; IIi ~ I_=. · ~-

< ' 3

' I I Iii. ~~ -~ ·t ' 2 - il 1 II I 1-1:~1- .H't 0 1. 1 - II.JJ ' .,

h.~f///4//~/;/d".f~ P' //4"/#"f/ ./ // /

.; [cGove~l'nlttD~t-Alh.-PtiiFIIfif\'J •~!lii'Nal\h.s_.pandlf"Q I

Sout'1:4: WHO NHAtntl, 2010

Ten leading sources of inefficiency l. Medicine: underuse of generics and hieher 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.

Strategic options to attain 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

Annex4

Global and regional indicators 1. General~:oVl!:rnment health spending: 4-S% of GOP

• Regional target: THE 4-5% of GOP

2. COP: Lower than 15-20% ofTHE

- Regional target: lower than 30-40% of THE;

Additional dimension:

·%of households facing catastrophic health expenditure;

·"of households impoverished annually by OOPs

3. Coverage: -over 90% of population covered by prepayment and risk poolfng schemes; and

-close to 100% coverage of vulnerable population with social assistance and safety net programmes.

Dissemination workshop of study results The financial burden of health payments

Fiscal space for health: options for raising sufficient funds

23-24 March 2011 Manila, Philippines

Raising sufficient funds for health

FISCAL SPACE

"capacity of govt to provide additional budgetary resources for a desired purpose [e.g. health] without any

prejudice to sustainability of its financial position"

Heller, IMF

G~mlMnl op.e.ndltwe on health as" of total ggvernm•nt expenditure: 2008 est

! : '--_-_ :--· ::::

Annex4

3 fundamental health financing challenges

2. Removing financial risks and barriers to access (reduce heavy reliance on OOP)

3. Reducing inefficiencies in resource use

Fiscal space for health

1. Allocate greater share of govt revenues to health 2. Mobilise additional domestic revenues

a Importance of GOP growth a Diversifying domestic sources of revenue a Domestic options for innovative financing

3. Borrowing (seignorage)

4. External aid

NOTE:

• Macroeconomic stability I fiscal sustainability • Health ++ Economic development

ASIA: low and middle income C.mbou -:-::::;.;.;.:

Chi"' I-"-'"'--'~ I• don""'~~:=!

,~;~·~'"'":-:.,;·:-""':-:'""'::-"'-'~:: Thalla~d ;.;.;.;.; .;.;.

Vittl'lam ""' -

Economic growth

Revenue to GOP ratio

- -

. ·· -- --·

Prior~yto

heakh

R)substantial

.Minimal

X Fistaldefidt>LS%

•Despite recent global economic crisis, substantial fiscal space in many Asian countries (in contrast to Pacific Islands and high-income Asia Pacific countries)

Annex 4

Assessing expected resources available to health: MacroHea/th

• Simulation model of fiscal space available for health over the next 10 years, given macroeconomic I public finance conditions.

a Simple excel-based tool (with user guide)

a Most baseline data readily available

a Scope for links to econometric analyses "t costing exercises

Examples of how it can help policymakers

• Econ growth forecasts have been revised up/down

a What are likely implications for govt spending on health and total health expenditure?

• Govt aims to increase its allocation to health reaching xx% of general govt exp in x years.

a How feasible is this policy likely to be(

a How much would GGHE increase if this was achieved?

a What impact would this have on other (non-health) departments?

Limitations

• Not an econometric or costing model. a Instead it is a financial planning tool

• Although offers 10 year timeframe, model most realistic in initial years following a change in macroeconomic environment I health financing policy

(domestic) Fiscal space indicators

Indicator Fiscal space Benchmark rationale

GOP per capita ~2;25% 2: 1 Y, times global average growth rate < 0.75% < half global average

Govt revenue as <15% < IMF report 'minimum' tax ratio 'Yo ofGDP ;326% 2: High-income country average

GGHEas %of <7.5% < half Abuja declaration total govt exp ;315% Achieved Abuja declaration

+ Macroeconomic constraints: Fiscal deficit ;;:. 1.5%; Inflation ;;:. 10%; Debt service ratio ;;:. 25%

Measuring Financial Protection and Health Service Utilization

KeXu

Health Systems Financing World Health Organization

22-23 March 2011, Manila

Dissemination workshop of study results: The financial burden of health p:~yments

The Framework of the Analysis

Provide evidence to improve health financing policy

Access to needed care

• 'Who needs and who uses health !ICII '\-ic..af'

• Who does not access needed seC\-ices?

• Who pays, how much a.nd forwhar kinds ofscrvites?

• Who suffer$ catastrophic expenditure?.

• How many households arc impoverished?

The Choice of Indicators

• PercentAge of households with catastrophic health expenditure - Y(ht.on tho ml!!diul hil ls. or~ or mQra of their members are high in relalion to

Lh t lrc.a(IIC\ly 1(1 p•y, hOU5eholdt m.Wt reduce their expenditure on other necz.ssilll!!l fctr . pcrlmi or time. 1Jlls 1 .. catastrophic expenditure.

- :1::::~kt~~~·! ~:;;~;! ;r;,c:ct~;.~:i~~)

• Impoverishment

=,=c''"':'-:-:l: -1~!. ~ip<31'1.!1'_1fl. pa.1'

- Difference in head counts difference berore and after aut-of-pocket health payments

• Intensity of poverty - Difference in poverty gap before and arter OOP aut-of-pocket health payments

~ Health service utilization - Percentage ~f people used service when perceived need

Annex4

Outline

• Analysis framework

• Methodology - Choice of indicators - Critical steps and assumptions in the analysis - Limitation of the study

• Mapping with policies

Utilization of Health Service and Financial Burden of Out-of-pocket Payments

Critical Steps and Assumptions

D.ata5ources

J ou,...inr; SES ua~ps I

Annex4

Household Expenditures

• Household consumption expenditure (EXP) - comprises both monetary and in-kind payment on ~11 goods

and services, and the money value of the consumption of home-made products

• Out-of-pocket health payments (OOP) refer to the payments made by households at the point that they receive health services. ~ ~

- doctor's consultation fees, - tCI.nsportation - purchases of medication - special nutrition - hospital bills - insurulce -Lab cosrs relmbursement - spending on ~temati,•e and traditional

medicine

Limitation and Challenges of the Analysis

• On catastrophic expenditure - Non-users of health services are not considered in the analysis - Household coping behaviour is nat considered - The analysis only reflect short-term impact of health payment

on poverty and household financial burden - Definition of household capacity to pay - Measurement errors and comparability

• On service utilization - Based on self reported nl'f!d which may res.ult from different

expectations ana nomts lor health as well as biases by age, 5¢X1 h@lth system indicators and other c.haraderistics

- Not reflect the quality of services - Instrument for data collection is not standard

Facilitating Country Policy Dialogue to Move Forward to Universal Coverage

• Where we are on the way to universal coverage?

• Why we are here and not there? - The three dimensions

• Which way moves us quicker towards universal coverage from where we are? .

• What do we need to do? - More resource, possibility? - More efficient (fragmentation and

alignment)? - More prepaid funds

Subsistence Spending

• Household basic food expenditure - NOT including nting out in 1 restaurant - NOT include alcohol and tobacco

• Household basic food plus other basic spending

• The inlern:~lional povcrl)' line - $1a day per person (1985), converted to loul currency, survey year u~ing food

PPP adjusted by household size

• Food based poverty line - the average basic food expenditure of howeholds whose foe~ share of tota1

household expenditure is between the 45th and 55th percentile - adjusted by equi"alent household size

eqsize,, = hhsize/ 11"'0·56

Usage of Financial Risk Protection Analysis

• Monitoring the progress of universal coverage overlim" and across regions (sub­national analysis);

• Evaluating the impact of policy changes;

• Diagnosing the system's malfunction.

Three dimensions of Universal coverage

1' .................. _. .• " f : l ' .

Unolt~

~-~~~:~.,.

OOP and GDP (in 2005 constant Int

·~· !~- ~ ·m·· ..... ·· .... -1111 . ·~ • I ! I • I , - I • ~ • !• I• !

!l! . I" ·I• ~

t~·· · ··m-(t~··"" -- ~ I• I• ~. • I • ! •

I • I • ! • ,. . . !• . '!. ------ ------ ------

The Equitap Collaboration: An Introduction

Ravi P. Rannan·Eiiya lnstituto for Health Polley, Sri L;;,.ka

& Equitap Network

Workshop on Dlssamlnation of Study Rasulls: The Financial Burden of Health Paym,mts

Manila, 23-24 March, 2011

Motivations for establishing Equitap

• Large health and health system disparities in Asia-Pacific region

• Evidence from Europe of the policy impact of inter-country comparison

• Awareness of the failure to institutionalize capacity in regional institutions

Diverse healthcare financing mix

Annex4

Large health disparities -IMR

Annex4

Equitap: Equity in Asia-Pacific Health Systems

Collaborative network of Asian researchers established In 2000:

- Research inslituUons, MOH pl:~n11l!l.;l~~~tun·r l:l., unlwn;Qln.h~IIII:Q\pyPtcrn• reseo\tcii:~~r~:nl:".a.

lnltlal.fund iOg by EU INCO­DEV grant, Rockefeller Foundati'on, WHO and WB Initial technical collaboration from ECulty Network (Erasmus, LSE) Current funding: JDRC, Au~ID. WHO, ADB

Equltap coverage 2011

Geographical coverage

• Tricountry Study: - WHO-SEARO funded project in Bangladesh, Nepal,

Sri Lanka

• Equitap 1: -Bangladesh, Nepal, India, Sri Lanka, Thailand,

Malaysia, Philippines, Indonesia, China, Hong Kong, Taiwan, Japan, Korea

• Equitap 2: - ... + Pakistan, Mongolia, VietNam, Cambodia,

Laos, Fiji, Solomon Islands, PNG, nmor Leste, Maldives

Internet Coordination

Equitap goals

Strengthen capacity for health equity research and analysis in member institutions Promote partnership between researchers in region

• Undertake comparative assessment of national health systems

• Promote improved equity in health in Asia­Pacific

How we have worked

• Development of standard protocols for analysis, standardized on Stata platform

• Primarily use of household surveys • Stress on analysis by country teams • Support for teams through direct training

support, mentoring, email consultations, help clinics at network meetings Website, Equitap listserve, technical guidelines, papers

Use of standard methods

O'Donnell, Owen, Eddy van Doorslaer, Adam Wagstaff, and Magnus Llndelow. 2008. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation, WBI Learning Resources Series. Washington, D.C •• USA: WoMd Bank.

+ Equitap Empirical Guidelines and Technical Notes

Healthcare financing tends to be regressive in Europe (1990s)

~~~IN ~~ ~ rr -<13 .:

' ~ -QA j

I -0,5.

• Direct taxes ~Indirect taxes • SHI • OOP ECultyRuults

0.7

0.6

0.5

OA

0.3

02

0.1 -

Domains of Analysis

Profile of health financing • Health accounts

Distribution of payments for health care • Progressivity of taxes, insurance, out-of-pocket • Welfare ranking using consumption

Distribution of healthcare use Targeting of government health spending

• Benefit incidence

Incidence of catastrophic health spending Voices of the poor. Public opinion surveys Policy frames

• Content analysis, surveys of policy makers

Equal treatment for equal need (ETEN) Health outcomes Comparative case studies

• Tax syst&ms, Extension of social insurance

Annex4

But healthcare financing tends to be progressive in developing Asia (1990/00s)

• Direct taxes J:: Indirect taxes • SHI • OOP Equlblp Re-sults

Annex4

Who pays for health care?

The better off pay more (absolutely and relatively)

In general, as GDPt, share paid by better-off falls and financing becomes more proportional, but progressivity also means better access for rich

Effect of economic development: - OOP7SI; indirect taxes 7 direct taxes - Direct taxes and OOP less progressive at higher levels of

GOP

Progressivity of payment mechanisms: Direct Taxes> Indirect Taxes> Social Insurance

~--------OOP --------~

Varying incidence of catastrophic expenditures

Households forced to spend more than 15% of income on healthcare

··::~l 11\dlaJ .....

H..oKotiii(Chl ... l

Talwan(Chlrl&l

...

Targeting & use disparities

Poorest qulntile share of non·hospitat outpatient services (%)

10 20 30 40 50

Impoverishment a major problem -r..:-r..,_.,..~""f.1Y.1'1 -f',u~...,;~ -~~~·~(~11*. -~~ltlhd~iJ~lS!

Bangladesh 4% of households pushed below $2 poverty line each month Most common reason for default by Grameen borrowers Single most reason for households becoming poor­also in China

Risk protection linked to reliance on out-of­pocket financing

•~ r-------------------------------------------

...

eaang\adeslt

a Kyrgyz Republic

• Koreaelndonesla Philippinese • Sri lanka

Hong Kong SA ..

Taiw~~~a~ • Tha\land eMalaysla

3K oiOIC. \IOI'IP; tcr'JI. IK

out~f·pDeket expenditure as -J. total Malth expenditure

eVietnam :

Targeting & use disparities Poorest qulntile share of inpatient care services (%)

HongKong,SAR iiliT11 Tatwan

South Korea

Sri Lanka

China (Ga.nzu Province)

India

Thailand

.. -~,." Indonesia .l'!!'---1------!-----+-----'-------l

10 20 30 40 50

Who benefits from public subsidies?

Public subsidies for health are strongly~ In Hong Kong SAR (Chila) moderately pro-poor In Mal.!ysla. Sri tanka, Thailand, Solomon lslanch; and

"""""~ pro-rich tl Bangladesh, Chlna, lndontsla and Vl r. r.am

Pro-rich bias stronger for Inpatient than outpatient hospital care; non-hospital care is usually pro-poor.

but greatest share of subsidy goes to hospital care and this dominates distribution of total subsidy.

Subsidies typically not pro-poor but are inequality­reducing in all countries except in Nepal:

Health subsidies narrow relative differences in living standards b/w rich and poor.

Risk protection achievable at low incomes through tax or insurance financing

.. ~.----------------------,

• Bangladesh eVielnam

echlna

e Kyrgyz Republic

eKoreaelndonesia Phlllpphlese • sn lanka

Hong Kong"-"'.

Taiw~~a)e eThalland

elndia •Nepal

eMalaysla

n.~.--~-~~-~-~M=.~-~-~~=---=~-~ Out-or-pccket expendllurfil as 'Y. total haallh expenditure

Some key health systems findings Performance generally correlated across dimensions of equity - Health oulcomes, risk protection, targeling Indirect taxation not generally regressive in lower-Income economies unlike in Europe

Tax funded systems - The best targeted health systems In Asia are tax-funded with

Integrated provision (Hong Kong, Malaysia, Sri Lanka) - Well targeted systems characterized by:

• Universalistic approach- no means testing, no explicit targeting • Concentration of spending on hospillllslinpatient care

Social Insurance systems - Generally only reach poor, if universal In nature - Nat attainable in poorest countries (exception Mangana?)

- fo~~~~~~~~~:~a~!~a~.n::;,cl~;g~~1~~~~n'g.~~Y,J;r;;:/1~!11~te far taxauan capacity

- Equity worse If schemes are not Integrated

Annex4

Equity performance of health systems Universalistic, tax-funded systems Sri lanka No/minimal user fees, no explicit targeting/voluntary self- Malaysia selection by rich of private sector, emphasis In spond!ng HongKong ~ towards hospltalstlnpeUent cere, high density of supply. (Solomon Isla s)

Non-universalistic, tax-funded systems Bangladesh User fees, means tes11ng, diverse ineffective exporimenlaUon Indonesia In "reaching the poo~ proJects. emphasis in spending towards India

X non-hospital care, tow density of supply. Nepal

National health Insurance systems Japan Universal social health Insurance, large tax-subsidy for Korea Insurance, emphasis in spending towards hospllelslinpatlent Taiwan ~ car a (MongoliaJThe" a )

Transition systems China Restricted social health lnsumnce, mlnlmallax·subsldyfor VietNam insurance, User charges major mechanism of financing X

(I -· · ·- :~,~:._~ :~~~-,._J'i,.;,_ ·n~ ~ .;..._R,.~ ~..:_

Tax-financing provides better risk protection in developing Asia

Households with medical spending greater than 15'/o of

Htpal _ ....

· household consumption ('/•)

Lessons from Equitap experience

Comparative analyses of health systems performance can be highly effective in supporting and influencing policy change

• Financing does not exist in isolation -importance of looking at financing and delivery in combination

• Capacity building for technical analysis within countries critical to facilitating local acceptance of findings and regular monitoring

• Capacity building takes time and sustained efforts and cooperation by all partners

Annex4

Health Spending & Results from the analysis of the Cambodian household surveys

Dr~ Piya Hanvoravongchai (piva@post harvard edu) 23MD.irh2011

cambodia: country Profile cambodia: country Profile

Tollll population 14million (][)J>_p_er caoltA $635 % U..der 15 yob.r!l old 36.9% ur. o:xpect=cy at blnh (M;IF) 60/65 Under-5 mortallly~ate 83/1,000 ~!$mil martAII!y mdo 472/100,000 Adull (U<-) lli=cynte 73.6% %pop with access to lmprov~ drlnlcingwatu 65% IIJt pop with access to "improved !Jinitktion 28%

Key Health Financing Schemes

+ User fees system with exemptions for the very poor, but in practice the proportion of patients receiving exemptions remained very low (mostly at health centre level)

+ Increased number of poor population covered by the Health Equity Funds (68% of the poor or 35% of entire population)

+ National Social Security Fund for private sector employees to start with employment injury coverage (300,000+ members)

+ National Civil Servant Social Security Fund was adopted starting with pension system with future expansion to cover health care

+ There are 12 Community based health insurance schemes in 11 ODs covering over 70,000+ population

Data Cambodia Demographic and Health Survey 2005

Cambodia Socioeconomic Surveys 2004 and 2007

irlt.nriiiWpcz:locl Od200Jtgt)ec:200.fo JU~to0.c2007 2005 SIUII;plt.Ne.

houuhald. 15~000 3,.5'3 I·Uf1 mdividu.ls 7f Jll VAl' 73.-GJO

•-~p--~d.:u!. Las14 wulu; 1Aat4.wcdtt ............ D.-.~1:1

& u• 14•06 ql4u06 ''" 1· '1'1l'diDMaa CJ.l4101 •li•-dl7• to aH.•c:CI7• ''" buh4 c.u•ulktr.a: qHaCII "':l.adt •h69, sh73, th17 • IJpcolpraviden qlh09 11ltaclD al!7Q, sh.1 .. ,.~ol\1i ... .,.....,... ql4.d0 ql·hc:ll ""' · d.ar • crfbct~ oql-bl1 lli.lt.cl l NfA -~~P~C ~tl4dl- qlhC1U t.'-'l.atV~thRI -buh.'t.t-!.o.lofol! trutr,nuf$ ... ... t.hn,ah.O''i.ih11 - -.JI IM'Inullp!IJOO Yu Yu NIA • U.Oflo&K a:tl.tlu ~lllu fram.COJISU!f lion fncJ. ~n~ lramwullhh:lal

Annex4

cambodia strategic Fram€\1\IOrk for Health Financing 2008-2015

+to remove financial and other barriers to access to health services for the poor and to protect the poor and the non-poor from the effects of catastrophic expenditures on health care.

+ to create the path and outline the steps towards the achievement of universal coverage in the longer term (beyond 2015).

study objectives

+ Incidence of illnesses and health care seeking pattern

+ Choice of health care providers

+ Health spending and debts

+ Impacts from health spending

Methods

+ Descriptive analysis of Incidence of illness and health care use

• Analysis of detenninants of illness and health care use

+ Catastrophic analysis using WHO Methods

+ Analysis of detenninants of illness and health care use

• Impoverishment analysis using national poverty lines (instead of food derived poverty line)

+ Analysis of detenninants of impoverishment

Annex4

'" Age group G!Yur2004

Provider choices 100~

75%

25%

% Ill individuals not seeking care

Economk:qurntfl• •Yut2007

"""" .......... • P1Mtt ~nrmZI~Mttnc5lllll • llrlnw~ .PrivntholpJQI5 .PublkhOJpiUII .PIIblll::hc,lthctftl.ers

-~_1.&>1\T _ ___ _

II 2004 '2.4/year II 2001 2.0/ ear

Incidence of Reported Illness

' . 0·5 5-lS 15·60 60+ p~) t1 411 N lhi&h~J

Detetminants of healtl1 care seeking • Econometric analysis controlling for illness type and other factors

• Higher chance of seeking care

+ Higher quinli!es

• Educated or male head of households (2005 only)

+ Lower chance of seeking care

+ Older age groups

• Rural and other urban areas outside Phnom Penh (2004, 2005)

% care at Health centres

% care at Public Hospitals m•

• 2004 • 2007 ~ 10% ~,_..,R

r 1.% " ' · ~~--- .~ -----·~ -...... '" 1- " ..-- 1- - . :·:-- "'

~ .. -

4% -- ~- 1- ': I·- ~ 1-

2% ·_r-_ ~-~ r- 1- r--0%

v O-S 5-10 15 · 60 60+ (lowest} Ill IV (hlch""l

Detetminants Of provider choice

+ Econometric analysis controlling for illness type and other factors

+ Rural: use health health centres and home care more

• Higher economic quintiles: use hospitals and drug purchase more

• Children under 5: use home care less (2004 & 2007)

• Male head of household: use health center less (2004)

Average annual ooP:~~~·~ • 2004 • 2007

64,788 Riels ($15,9) 60,434 Riels ($14.7)

501)000.0000 - ·•--"

"'""'- --- --- ------- --- --lSOOOO.oooo - ------ ---li M---·---

-

Annex4

% care at Private Hospitals

I v 0- 5 S-10 15 - 60 60+ (lowest) Ill IV (highest)

Average oo P per visit 2005 --r-«•oo;,;oo~o~::::::::::::::=

Annex4

Transport cost for health <2005> + Average spending on transport to get health care is 8,004 Riel

(US$1.9) per capita in 2005 + Avearage transport cost for first visit is 3,391 Riels or approximately

10% of the average OOP + Significant differences in the travel costs to reach different types of

health care providers ·

Average OOP per capita by type

________________ , ______ ,

o o P by type of care 2004 vs 2007

• Vls~OPD • IPD lfl Other 100"

75%

SO%

""

,.,_..., V~J

Average oo P per visit by type ...... ~~ ~--------1-----4------------------------~ "'""" ------r ·-- --·~ .... ___ , ___ _________ , __ __ ~ ~----~±~~~~~--------------------~

~-

Annual OOP per household ..,

i 2004 2007

00\~ 750,000 • UQm~Q,.,

~ 8 Ph;ITI'!I~£iM ~n:lilC~5 .. • ... t~.:O!"'d.~

~ B P6r~lthospil.:lb • P<:blitiK!qllt-~k 'ii 500,000 •. H.C:>!k.~.~~u;t5 i

l ""·"" !i ~----- --1 '"" • c C o:. - Ill IV Ill IV v

oete1111inants of health spending

+ Econometric analysis controlling for illness type and other factors

+ Chance of spending money + Higher chance: higher quintiles, Phnom Penh, male & educated

head, hospitalised • Lower chance: bigger household size, older age groups, male

+ Level of health spending + Higher level: higher quintiles, hospitalised, Phnom Penh (2007),

Male (2004) + Lower level: bigger household size (2007), male head (2004),

teenagers (2004)

Medical debts + Incidence of debts from illness decreased

+ 5.3% <•·•""·' ,.., in 2004 to 4% (3.4'H.6%l in 2007

+ Average amount of medical debts per household increased (not statistically significant) + 30,467 <''-"'·"·"'l Riels in 2004 • 57,386 (35,77>-78,997) Riels in 2007

+ Fewer households with debt but bigger size of medical debts for households with debts

OOP vs capacity to Pay

! :: E- . ·-·-·-· -----~~ !:! uo ---- ---u +i-.-llr.;;--l!f

if ~

I -·· -ZOO.Cout-of-poc:.kettltplndlturea$1 shlreof~ilpac.lc.y.!IHI'Y

~200-4Coapac:lty-to-pr(

v {hl~st)

l:i;l:i;il;!2007out-of-poc:l:etnp•ndlturrill & 'h•r•ofupac.iruy·lo-p7f

-:6:-20D7Cipatity.to-p i'f'

Annex4

Impacts frcm health payments + "Sometimes when we are sedously sic/v we have to take out a

loan at very high interest. If we borrow 10,000 riels, we must pay 1,000 nels interest every month."

+ -Poor women in Kompong Our village, Kompong Chhnang

+ '11 is harder and harder for us because our income is just enough for buying nee. Whenever any family member falls sick, mostly we go into debt or have to mortgage or sell our land. After recoverin~ we then become workers in the village or have nothing to rely on any more."

+ -Those fallen into poverty, Khsach Chi Ros Village, Kampong Thorn

• Source; Wodd' CLank'.;; EqWly R~pprl- 2007

Impoverishment

nt IV v All

catastrophic Health spending

10.0%

9.0%

..L 8.0%

7.0% m 6,0% .L

S.O% T ~ !"i 4.0% - r-

n~ ~

3.0% !f1L ... ~. - ;--2.0% d i= ---- ;--1.0% ~ ;- ;-- Jr- l .2004 0.0%

1 I Ill I I .2007 I II IV v

All Quintile

Annex4

Determinants Of catastrophe

+ Econometric analysis controlling for illness type and other factors

+ Higher chance + Rural area + Hospitalized + Others (2004) : higher quintiles, have member under 5 years old

+ Lower chance + Bigger household size + Others (2004): educated or male head of household

summary of Findings

Significant improvement in Health care access ill people seeking care more higher use of health centres among lower economic groups Financial protection lower OOP share lower impoverishment and medical debts lower catastrophic incidence

summary of Findings <cont.>

+ Remaining challenges + Equity in health care access and financial protection

+ variation in utilisation rates across population groups + > 20% of lowest quintile did not seek care when ill

compare to less than 10% among highest quintile + rural households have higher catastrophic risks

+ Potential rise in health care costs and financial burden

Key determinants 2007 2004 ..

Higher chance Richer quintiles Richer quintile.o Hospitalized B<>Spilalized Capital Elderly, adults

Malo Lower chance Bigger h ousehold size Head Male

Teenager>~ .. ,, . . .. Highet chonce H95plt~d Hospltall7.ed

.Rurol Rural Richer quintiles Onder-5 years old child

Lower chance Bigger household size Bigger housellold size Heod Sec Edu, Male

International comparison EXHIBIT2 Distribution Of The Incidence Of Catastrophic Spending Among Countries, By In came Group

e • Ill-• Med".an

,..._. ________ , __ __ • Upper

"'"' • o.oo 0.02 0 .04 0.06 0.00 O.:ID

Source: Xu et a! (2007)

Healti1 Financing Goals

+ Cambodia Strategic Framework for Health Financing 2008-2015 + to remove financial and other baniers to access to health

services for the poor and to protect the poor and the non-poor from the effects of catastrophic expenditures on health care.

• to create the path and outline the steps towards the achievement of universal coverage in the longer term (beyond 2015).

+ Asia-Pacific Health Fmancing Strategy + OOP not exceed 30%-40% (currently 65%) + Health spending at least 4%-5% of GOP (currently 5.9%) + > 90% population covered by prepayment (currently <50%) + 100% coverage of vulnerable populations With social assistance

and sa£ety-net programmes (cw:remly 68%)

9=t 00 ~.x1Mg:~~3l: ili B<JWF~ Research on CATA in China

Keqin Rao, Ling Xu and Yaoguan Zhang

Center for Health Statistics & Information MOH, China

lf:}J:ftffi(BACKGROUND INFORMATION)

~: AOltl-&:, 2000-2010SJ'M:i a l20il;Jj!:lmi!Jl3.4il;

" ~il'f2tlik 200D-1010~P'j ~,::o~Jo~:~tu.J ~.::::;f~,_ ::;!Qoo-ioio~~~**' ,!;"GDPI:t'l!i:II!39%~J.ql~J48% U AR·-201iil -2ofo~«:. 1£/$i! lii ~o'iioiit·M~~9% !!tJlJ&A, l.ooo:2o~o¥Mi.!l:<& ~JJo·7~.91fo' -·

The State Background

~ Population: ln the past 1~ froill 1.2 Billion to 1.3<\BllliOn E-conomic De.v: In Jhe past }-Oyti: AAGR.l.O~, Pe~.capita GDf noS" Increased by>.14 timos: &.to 4000 us$ . . s.e~lces indus.try : lo tho past _lOy(' ,_By 99% afGI;>p incre~d to 49.%'; uiban.Pap.3o)l(2~-~) to 4~-~-(2Q1D)

ll S~te Re~enue: In thep•.rt ioyrs, ~itn lncian~ 4.9 times

t:j:l ~.Jl~~Jt ffl ~t!J~3t{t(1978-2009) Composition of the Total Health Costs in China

Annex4

11i.l!fi*J~ (Contents) "''if:lil::ft-m

~ illlt.lUI: n Jl1o'tlfl

11: Introduction ~ The state background ~ Health expenditures

~ Jl1oJiili<J<l!i a Health financing and reform l'i !iJf~:lill<

~ IJ!lt!'J§!'J • l!ifi!'J*i!J ~ IJ!5ltt*l&l!<

"!iJf~~>l! ~ Jl1oll!§'<'i'J!ll ~ ~f;l!l>Jl'Jl1o~ Jil ~ ;1(J<i:!Jl1o'li:lil ~ i'lll:ll!ll'I?Hif "lll'l'l'I'J!llillilt:itl!lil!

"' i>Ji%

If Research Method ~ Objective ~<: Data Resource ~ Study Method

r; Research Results r:. Utilization w. OOP ~ CATA l'! Poverty Causes •· Impact factors

r~ Discussion

lf:!J::fl-ffi(BACKGROUND INFORMATION)

.Jl~sttl:l THC <!>E!I:E.!tl:tJil:z,ut.!;'GDPtl::!tti'J3!:{t Olange of T_HC &. Ofo 1?-f ~OP in China

20000 ·-====--=- - --, Total Hejl_lth ~sts: 2ooo·-18000

-:EUmm<!Zi<l 21110 :rHC ha• !ntrellsed 3.26

16000 - ,!;'GOPtti1l

Urnes MG~% • . firJcaplta ioii~s*

14000

12000

10000 :rlietGDP~ ~000-2010 Th'C. proportion of GDP by 4_.6%''of up 8000

to ~-,1% 6000

OPPfTiiG) 21)\}1!:20¥JJPP "" Prqporti<ji\ of TIC by 59% down zooo 0038%

284.67

313.20

345.76

369.22

385.89

44U3

4

2

Annex4

Major progress in Basic Social Medical Insurance in China,2010

. ~Iii, 2010~:!Efll~ ~.6~· - ~1ii4.29 fi;, ~8.34~ .. ~il-.!Jl 95%

If -~lf, 20~0~jo~ !l!iol~12·o~Jil2oo]n . ;!!;Itt {;l"W:~J)Ji&J,. G i!. ~.!li"la~!i:il'!I60'fo fd!IJM/Jt, 2010¥9'~U Jll -T5E1Yrub~Muo fz.. lt2oosq,9T-w

J; ~verag¢:. 1:26 H~ Peoples in BSM[.: Ur~an 4. ~~ HM, R_ural

8.34 HM, ~~~'? ~~%·

G. lEweJs; ·~ov~nJm!;nl er<!l)ts for a person 120 iii ?OiO ~0 200 in 2~~1 Ceilin"g for f~.i~bU(se.menhYiU be

6 times .t~e saliry-,

ReimbUrsement ratio 60%

" ti Medical As5ls!ali.ce Scheme: The·

c~ntrcil Bovemr:nent fundsllOHM in .i010, More th3i'\ doubled' in Os

WF~:::tJ:r! (Research Method )

• ~§-illl'f • lOD"'''~~ s:nlEI'

If, /fliO~rul!iiB,f.ili!il:lf ·~n\'17 • "l11 lli.A.o~iA~

1S-49!/11rM"i!l.1Q!I3'i • s;tl!l"F;~t~&Qiill!l-• 60'"*~ill~.AC\11l:f 6 jlip.l;\;lliiill! .. ~F.l;\Ui • iiW>A"c-\l'.di

Data resources

• NHSS • 2003. 2008 : 50000

HausehDides

HHQS & _S_pciat ec.Dnomlc stat~ a Health status and rl•I<Jactors ~ 15·49 w-;,man h;,..ltl(sbltllS ~ 0·5 chndran health 'stafus · <II 60 and ovnrp<!ople health ii Illn$ & di5abnlly In 2ws • HospttaUntion1

• Floating p~bple health

~tt::E.1:xtll~)EI'!9ti(m (Criterion for CATA)

WHO-op 1;§1 OO.ii<:ntlil'li.<ti'!9~ (Difference of poverty line between WHO and China

1ll~I*J~ (Contents} .. 1\'j(1)-ill

• lili<lllil: ~ JHtl:.:ll ~ l!.'£!0i!ie}::i\t

l1i ~~/iii • ~~il'l~l)

= lliflfll*ill •· IJI'il.lf*:llll.

"'~~!'li~ ~ l!.'£11il1t'l'J!II ~ !lf;Jiltfil!.'!:!i!Jl! • 11lllttl!.'£;i:lfl ~ Fl>tiUJ;Hii ~ ll""'l'l!llfi'J!I>;i<l!li!i

"'i;j~

1. 1tB:i:lfH:t_. f~;;r.rr;.~p. -~ e:p.

2. ~ifl'itlUf .. , tqs!~.~Jo • l!lu i:l•1 ~-''

ro Introduction If' The state background u Health expenditures t: Health financing and reform

11! Research Method c.: Objective ~ Data Resource ~ Study Method

'" Research Results a. Utililation ~ OOP ~ CATA It Poverty Causes fl:. Impact Factors

"' Discussion

_/7~)t>T, • l if • XPJo •: 'H",~o

_vco.:>T;. • 0 if exp, ~ SC"•

8. li<ll:i:f.t~:IJ(ctp)

10. ll<>tl1l!'£:i:l!!(cat.) :l/~11 .. .. l co~;x.-p. :.:, 0 .&

.:"'rc. -c• u: "'~~..,:,P,. •:. 0-1

1ll~I*J~ (Contents} "''IUI:MS

• l!l;t;)f;J< ~l!.UI!l ~ l!.'!:Oillia:t:

111 ~~:fjit; ~ IJt'il.fll~il'l

w lliflfll*lll ~ ~'il.1t*14ll

""~~!;!;~ ~ l!.'tl£91-'l'lll! ~ !lf;jll[ffl!.'£~!11 p ;l<:l!lttl!.'£:tlll ~ l!!'!tW.E!I~IIi " ll~lll!il'lll>:tl!i:ilt

~ i.;j'i~

" Introduction M The state background 11:: Health expendlt\.lres rt Health financing and reform

It\ Research Method "Objective rt Data Resource e: Study Method

"' Research Results e. Utilization ;:: OOP ~ CATA ;;: Poverty Causes e. Impact Factors

Ill Discussion

Wf~~it5!(!: (Research Results) 1 . ~ft!K!i!1R;illlt~lll. 1. Changes of Health 2. i1Uflt!!IK!i!1 R;J!.1:.JlHl-'f1J Status

J1l 2. Utilization of Health 3. i/:IHIK~~Ji!1R;f1!tff"l'.lt Services

Jll]it~{t 3. Changes of Health Cost 4. ~~;i(li!i&~llUtfl 4. Changes of income &

5. ~~!X:~f£11!'iff~tfj;it1:, expend

1fl51. s. Probability of the CATA 6. ii~Uf£11!t1T~tfl~ft 6. Impact factors of the

~HIT CATA

Coverage rate of different insurance in China r·-- I -...,.A..,..,LL-,.......,U~rb,_a-n -;1-R"'-u'r"...,.a]- ·1 tType oflnsurance 1'2oo6 2003 zoos 2003 zoos"· "2oO:i i iP..IIl!H~ , Ins, of Em~oye~ 12.7 6.~T~ 44.2 ~-4 , ~ ::.. _1.5 '

~Jllll!117 Free medical care _ 1.0 1.2 ~ 0.3 0.2

W!i!l~ll!11* URBMI -- 3.8 ~j___9.2.__ ~'llii'loll!117 RNCMS .. --.. ~B.~T 6.8 _ 9.5 ] 6.6 . 69~:_

j !'tit!!t.t~ll!11* Other 1.0 1 3.3 j 2.8 8.6 0.4 1.4

:.;a~fl!1Q! No - ·-;-;:9 [ 77.9J 28.1 1 so.4 7.5 , a7.3 1

Annex 4

iJiil:itt~l8:: £;;fs:·M'~~MJ.l~~

The Coverage in different income people in urban China , 2003

100%

80%

A. 60% i:l t;J 40% !ill

20%

0%

Annex4

iJi\llr:lt!!IR: ~~f±f'~m.oc~mm. Sample Region: Poverty Headcount

iJi\llrii!!IR= *~J!~xti:I.2Utr!J,~stti:I!¥.IIt17lJ% Sample Region: Household Health ·costs&. %of Total Costs

ALL

iJi\llrii!!IR: ~~~~ffsttl:l~~ffl~ Sample Region: Catastrophic Payment

~------~u7.~=r--,,

':-c-:--.-::zoo='a "-'>OOlTij

~~~g, ~ff~*~ffl~~~~~~~ Sample Regipn: Impact Factors on Medical Services

!!:I: All Urban (it}0);;~_ lrj~.-_ t.,_;...e~o;r.2£1\f.l . ... i' 1'

tl~ ')ID..MIH · -. ,. -I i ·If r QA1to..i7 O.,.W' U7{Q.l0 OM) .P'E-.U. ~j a:l'6(o..z4 QJSJ _A..!!(ra7~U~

~::-:r" -= :::: .. -~~~ H~W. ~-H~liUIIII'I-&l~ ~~

:P(J. )iQ

F~~ ByAc:,OrMi, • , _

,... .. '"''"'"'I -

-~~::~~~ O.liiiO.l.4"1UJl 'a . slfO.~-~IinJ

' 0.11{0,6l'il!l)

~~J 12f} ;Lipfi.~ 0.11\q:n ll.§G} 1'~1~)

l..S2(t;D WI

-a.niiii.UJJ

~~'l.Uf o::t!\a.100Zl

Sources of data

1. Lao Expenditure and Consumption Survey (LECS3), 2002-2003

2. Lao Expenditure and Consumption Survey (LECS4), 2007-2008

~odV'~--­..;~·r--

Results

Reason for not seeking care too% ... --.-=-....-:.-.---- ...-,..-,..--..-~ ....,......,...

90% 1t -Bo% - 1-- - 1-+ ··· - .... -

t-·- -·1--11 .... +-1-70% l 6o% ~----I--I--1-+----IHHI-Ir.-5o% !.1-·l---1-11-11---11-1- 1-40% +11--11--11-11-1'-1---1-1--11--IHH-30% t -2o% ~---------1-+---1--•-IHI-II-+ to% +1 J _._l-1·-1·+ - - -1--•-1-

~ '] i5],4~1~ ' 2002./2.00~

a&&&ii !l,l g ; -5 <~ !., lo:. J 2

i 2007/2oo8

IW'i No cure possible ., Not good quality • Too expensive • Difficult to get there • Not serious enough

Data uses

1. Diary expenditure section

2. Household composition section

3. Health section

Use WHO methodology

16 .,.------- --- - --

14

12 i

r: l ~ 6 +

4

2DOJ/2.oo8

Annex 4

• Seeking care in health facility

Distribution of ambulatory service utilization in Lao PDR by quintiles and types of health facilities

"' 0 .70 ...------ ------

~ o.6o +------ - - -----::­~ o.so +----11- ,....-- - ----..--!1! ~ t 0.40

"' -~ 0.30

·~ 0.20

~ o.1o +i!HI-IHI--. -; ~ 0.00

•Other • Hospita1/clinicabroad

• Private health clinic

• Public Health center

• Provincial/dis[rictHs

•CentralHs

Annex4

Distribution of hospitalization in Lao PDR by quintiles and types of health facilities

t.oo%

o,oo%

Poorest Q~

3

0

Poorest Q>

!?. Other

• Hospital/clinic abroad • Private heo:~lth clinic

* Public lluhh center

• Prmincialldistrict Hs • Central Hs

Q4 Rkhest Total

Richest Total

.l0 00./2003

• ~007/20o8

•l002hoo3

•2oa7hoo8

Average HH OOP per month payment by quintile 120,000

100,000

Bo,ooo

::: ~ 6o,ooo 0 . ...,

40,000

20,000

Poorest Qz Q4 Richest Total

.1002/2003

• 2007/2008

,~--::n~hly HH OOP for m~~~lnes 100%

90%

So%

6o%

so%

40%

30%

20%

JO%

o%

T

t I

~ 0

&.

-

·-

-a, s,cY: ~ ~~

:i!l F i

2002/2003

I

UM'

J I 'Y'I ~ I J I ~ ~oo7hoo8

• oop for other care

ll oop for medicines

Impoverishment incidence by quintile

> Utilization of health facility: • Combined data for provincial and district H • Combined data for health center and specialized

health care centers • No data about health insurance

i Health expenditures: • OOP payments include OPD and IPD spending • No data on expenditures of OPD • No data on transportation

~

Annex 4

~ :;:;;. 111~~~ ~~ :"•W~ '~::.-'. ,c~ .·' "F. •: !t".:;;: ,:;;•,ii-:;-~'1""~:.-:•.'.': . • •• ' . ~ • . ~ . . 1~~- ·-r~:

() ~f!li1Hcanl•f O.l,. ()•J!i!nlfiC.n• •c o,ns -

"' C<lef IProvlnclal and 'tli~ld hosuhols __j,

Mole 0.81> (-j ~~en under-=tge S 0.89 . Pt!rmn .o~o~e.r OJKe 60 0.77 "(·l !'moil .h.J-lon•·mm il~disablUtv 2.62' (+)• Per cooito HH "-"'""l'lliue por month i.oo ~ ai' l.SD 141' . Q3 . .. us (+) '

o.4 . ,. ill [+)'

o.s -~- 2.01 [.;.J•

Urban· us +.

~~c.r20CB .. ,, "'" 1.90 ~+)"

} Low utilization of health facility: • Poor people may not afford to pay for health care • Poor may choose to not seek care when sick • Geographical difficulty to access care

;. The richer, living in urban areas have more access to central hospitals (bypassing the referral system)

' And the poor living in both urban and rural areas have greater access to Provincial /District Hospitals and private health services

Annex 4

• Decrease in incidence of catastrophic expenditure between the z surveys

:. Low catastrophic: • Poor people tend to spend on food consumption

more than health care • Low utilizations

> High prevalence of catastrophic expenditure among poor people

" Poorer and households with under 5 are more vulnerable to catastrophic status

Recommendation

• Regularly improve quality of services of provincial and district hospitals as well as in private services

• Reduce financial burden for vulnerable and at risk groups

• Enhance the existing financial risk protection schemes to increase the coverage

• Improve data collection instruments on health expenditure for national and sub-national surveys)

D.Chimeddagva, Economic advisor of Minister of Health, Mongolia

Manila, March-23, 2011

·"'''" :~..:.: -~-

Introduction

21)00 2005 2005 2007 2008

4.1\'' . J.J~ ~ "3.4~' : •• 3t5'1

10'i113 - 1So40 Z114!17 0: ' . •

<5861 IH2

~J!l ~~ '19:531 "'---~ .

rliiilllliin~ ·so tl rces: r ~ fro!. ~;;:; :19'Ji

200!1

MODI..-. i· -~--· · ' 611 511 . ~~ .:a~~ . ~ ' '3% PHEG/It.':i~ .. ..; .. .., k- ;.- '· =-:·[.,t; .. I. ' h " 1 ···'L I~ - ·, j

I ;';&.~~,. ~- ·a .. ~ . - m: ~ ~il" •· A 11!. diii. l '2i;r, ... :w. 1 so..,£,~~~- ; .1, -~ - J~ : .Js211 4211 ' ··alii ~~~~~~ ~~.... 1 I,, iS~ , •<i71.% ~ -,m •c ~ · -"2<~-% ~H~, ,_,...,.., .. ,,, ·· ~ l,,, .~. · ~~ ·-·<;:;,_"2~· - ~,.. ~e..z~ . '- .7i ft~fo 23%

Annex4

• Introduction • Study methods • Study results • Results summary

Land 1.6 min km2 Per capita GOP $1,669

Total population 2735 BOO GOP growth 6·8%

Male 48.9%

Female 51.1% Consumer price 4.2%

Urban 62.6% index

Rural 37.4% Budget overall ·5.4 balance to GOP

IMR (1000 live births) 20.0

Foreign trade -252 MMR (1 00,000 fives births) 89 balance,

min USO

~~~~evrof'tre~tf;fn<~ncrug..~ co,.-

;;'if~ 1nanclng sources Mix of general taxation, public health insurance and out-of-pocket

and services payments overed

- General taxation funds: Primary hospitals, Public health interventions and fixed cost of secondary and tertiary level hospitals. • Health insurance covers: Hespital Jnpatienl an~ outpatient sel'!lces - OOPs for diagnosis and tests, private ~osp!tals, copayments for Inpatient care at public hospitals

~ervlce providers Mix of public and private health care providers

urchasing Population based resource allocation to prtmary health care lpmviders - Case based payment for secondary and tertiary level hospitals

Annex4

since 1990s • Revenue collection:

• Social health insurance • Private source of health financing emerged

• Purchasing: • Private hospital contracting by SHI • Result oriented planning and budgeting in accordance with

Public Finance Act 2002 • Capitation funding for primary health care • Social health insurance scheme implemented Cased

based/DRG funding methods for hospital services

I ~:.-~·-----"'-l .~~.e:--"'-~ ---- . -··-~ Study objectives

• Who uses what type of health services? • Who pays how much and for what kinds of health

services? • How do these payments impact on a household's

financial situation? • What kinds of households are more likely to face

catastrophic expenditure?.

Study results

Study method

Data sources

• Household Socio-Economic Survey 2009 • Sample size 11200 households with 44028

persons • Represents the total population:

• 613272 households with • 2735800 persons

Total household expenditures Out-<Jf-pocket health payments Share of households who spent on OOP

GOP/Expenditures Expenditures on medicines Expenditure on outpatient care Expendnure on traditional health Expenditure on inpatient care OOP/Capacity to pay

Share of households with catastrophic expenditures

Mean

188761 9231

29.1%

3.2% 6468 617 1545 529 5.5%

3.8%

Sldev

128883 64300 45.4%

8.8% 41678 15718 23457 10003 13.4%

19.2%

901; ·- --- - - -

80\i f--·---~--·-·-f""" " " 70% '-'l 'l--fil------~l--

60i. t-,~tl-----!r!---t

40% -t--!!---lli,----!,lf--ft---lll-~--tt-- ooutpoticnt """' 30~ ??·- ... ulllzilllon

lU ho~pilali'lation 10"-

0% .LJ!O""'-''--'"""--"

Total

quinlilei{poor toridi}

lfypes of health care providers Number (2009) ~rimi!IY level care providers : --.l'_{'. ... 558

F amllv alOUD hospit<ll 226 SLV!l hO.spUals ;- "01 lnler-soum llasPilals 35

Becondarl level rospllals:- _. ., •• __"'.-_I' ,I .35 Dlstrlcl hospitals 12 Rural !llln"e!al hosplfals > '.I 6 Arnag oeneial hosiiltals ·- 17

ertlarv.ievet hosOitats: ,.

20 R~~glol1al Trealinenl and D@l!oostlc lfosp/tals . -4 S/lWalalzed Cent8!S and HospitalS 1 ' 16

~atemltv hospitals 3 ::>lhe!S hcsbHals . '----·~ _:.J;,_ -' 49 'nvate "liospllals with bed

,. 160

~iivale.llospl[als for outpaliens 922 analo~a - ' 13 -

100% -:--c ..... - --...-r- -..-----.- - -.-..--90%

SO%

70%

60'X.

50%

40%

30%

20~

10%

quintlles (poor to rich)

5 •

• o~p_other lfoop_ip •oop_o;. •oop_rncj

Annex4

• lack of civil registration, (migration) • insufficient income, • being uninsured, • distance to primary health care providers, hospitals and drug

stores, • insufficiency of transport and communication facilities • lack of public health education.

5

quintiles (poor to rich)

l 4 5 Total quintiles (poor to rich)

Toto I

1!10~0%

Annex4

3

{poor to rich)

Results summary

• The share of households with catastrophic health expenditures was 3.8% of the total households. • total 23488 households have experienced the

catastrophic health expenditures in 2009.

Total

• Out of total households, 1.8% was impoverished due to health payments. • This accounts to 10855 Mongolian households in 2009.

• The health service utilization has been fairly similar across most quintiles except the poorest population.

-~- -,~eSults summary

• HSES 2009 results show that 29.1% of households have made some out of pocket payments on health services.

• Further, the analysis indicates also out-of­pocket health payments (OOP) take on average 3.2% of total household consumption expenditure.

• Out of pocket health payments are on average 5.5% of the households' capacity to pay.

·:· Rich and middle class population pay proportionally higher OOP due to: • Increasing interests and trusts to have diagnosed and treated overseas • Reliance on private hospital care • Informal payments despite covered services at public hospitals

·:· Both poor and non poor pay most OOPs on drugs: • System of prescription medicines has collapsed • Outpatient pharmaceuticals are partially covered by HIF and not effectively

Implemented. •!• Not only poor, but also rich should be protected from catastrophic health

payments • Insurance package should Include health services by emerging advanced

private hospitals in Mongolia • Improve quality of health services

:J"<<IIr: :: . ::=------.::

-PoOcv implication-

• On the general national policy level, OOP policy should be clarified and strengthened, for example • OOP should be monitored by reliable heath expenditure

estimates • Pooling and purchasing of health services should be improved

• There is a need to improve the policy to ensure health service utilization by the poorest of the population • Accessibility should be improved {ADB is implementing 2 projects

with MoH) • Improve HI coverage and insure especially the poor people

• Strengthen the SHI based health financing model by improving health insurance system:

Annex 4

• Strengthen the capacity of SHI as a purchaser by ensuring independency of the health insurance agency

• Extend population and benefits coverages of SHI by increasing government subsidy for the poor and informal sector.

• Gradually pooling public financing sources to HIF to effectively purchase health care services using greater financial leverages (reduce cost, improve quality)

• To increase public financing and investment: • From mining revenue

Annex4

Burden of Health Payments in the Philippines

Rouselle F. Lavado, PhD (Philippine Institute for Development Studies) Valerie Gilbert T. Ulep, MS (Philippine Institute for Devclopm4!mt Studies) Lelzel P. lagrada, MO, MPH, PhD (Department of Health)

OOP has increased in the past decade and share of SHI in health spending remain to be lowest among all financing

sources 1995 2007

Soult!soffuads

""""" ss Total Health Expenditure is Php 87 .lB (3.6% of GOP)

Source: Philippine National Health Accounts

Total Health Expenditure is Php 225.8 B (3. 7% of GOP)

Objectives

• Estimate health care utilization

• Estimate the burden of health payments

• Estimate the level catastrophic payments and its determinants

• Determine the components of OOP

• Estimate the level of impoverishment due to health payments

Philippines

Increasing domestic economy despite global fiscal challenges

• 7.3% Growth (in GDP) in 2010 and anticipated to grow by 5% in 2011

• But inclusive growth on social provisions for the poor like health care remains a challenge.

Fra Problems in Health Financing:

ented health financin s stem

Source: Department of Health

Sources of Data

• Health care utilization - 2008 National Demographic and Health Survey

• Catastrophic health payments, Impoverishment - Family Income and Expenditure Survey {2000,

2003, 2006 and 2009)

Methodology

Health Utilization

Quintile shares of inpatient care utilization, by type of hospital

~ .-··- ·---------------------------------­~ t--------------------.. ---r"--"'"----------~­~ ~------------------------·-------~ ,,, ____________________________ _

a » ~----------·-----·-----------~-----E u i-~------~:------.~-----,r ~ " i - .... r-----1'5>jl-------r'!I -----.,·--D C1 ,. i-!'>'lf-----~1------li-!'1

,. i-!'-~1-:-----1~':!1

ll'liddl~

WealthQuintile

ltPubtic WPrivate

Burden of Payments [OOP/X]

• Poorest 1: Richest It Philippines

Annex4

Results

Health Utilization

Quintile share of outpatient utilization, by type of facility

-----------;-·-----·-·--·- -----"-' ___ _____.....__ __

Wnll.hQ.uinti!e

•Ho."{lit:ll Public • H~11::1 rm~lf •Non-hospit"l Publi~ a N(Io-hollpll.!ll Pri,·nte 10

Catastrophic payments [OOP/X]; z=40%

Proportion of households exceeding 40 percent of their capacity to pay

2$ --------~---------------------------------

middle rich richest Philippines

Wealth Quintill!

• 2000 • 2003 .. 2006 • 2009

u

Annex4

Determinants of Catastrophic Payments

fil' 'lk< ,ifio ~~..,- ,I =·· ~.d:u;;:~;,c;,,., '·"'''~iil!N':;i· '~ ~ ''!<>'> ~-"' ."""I' ~n{urtia.n~ rur~ -Q.~ 0.00 Q.lj98,

~"' ·1.1 0.00 0,113

P....•ll•' 1.d4 OJXI o.1Do '

0.1lll;l "

Impoverishment

Policy Options

• Increase financial risk protection

• Strengthen supply side

• Increase fiscal space for health

Components of OOP Distribution of out.-of·pocket health expenditure compone nts, 2009

Poorest Richest

• Meditines • Hospital Charges

a Medital and Dental a Other Medical Goods

,.; Olher Medical Sevice s e Contr.ace ptNe

i:'. Food Suppli!! m e nt

Summary of Results

• Segmented hospital system • Higher outpatient visits in hospitals compared

to non-hospitals • Catastrophic payments are relatively low, but

there is clear indication of increasing trend • One percent is impoverished due to medical

expenditure

• Medicines got the lion share total medical expenditure

Creating Fiscal Space for Health

• Raise taxes: Restructure existing laws on sin taxes

• Promote expenditure efficiency

• Consolidation of donor grants through the Sector Development Approach for Health

BURDEN OF HOUSEHOLD OUT-OF-POCKET HEALTH EXPENDITURE IN VIETNAM:

FINDINGS FROM ANALYSES OF VLSS DATA 2002-2008

Hoang Van Minh, MD, PhD Hanoi Medical University, Ha Nol, VIetNam

&. Nguyen Thl Kim Phuong, MSc

World Health Organization, Viet Nam

Manila- March 23-24, 2011

·:·Area: 331,000 km2

·!·Administration: 63

cities/provinces

·!· Population: 87 million

• Rural population: 74%

• Under 5 population: 9%

·!· GDP per capita (2010) : 1,200 US$

Per capita health expenditure (USD)

,.., "" -

Contents * Health care financing in Vietnam ¢ Research objectives * Key findings ¢ Policy impl ications

Key reforms

Annex4

1989 Introducing user fee policy and authorizing private health practice

1992 Launching health insurance schemes (compulsory and voluntary) at the national level

2002 . Establishing health care for the poor fund (Decision 139/2002) . Issuing financial autonomy policy (Decree 10/2002)

2005 Providing free health cares to under 6 years children (Decree 36/2005)

2006 Revising financial autonomy policy (Decree 43/2006)

2008 Passing the Law on Health Insurance (In effect from July, 2009)

THE as 0/o of GDP

,.!:'. ~ r- -~

;-=

F t I-- r--- - 1- - - i-

i~

"" 1- - .- - - - -

r:

~·

Annex4

Health care financing in Vietnam

1. State budget

2. Health Insurance

3. External aids

4. Out-of-pocket payments

S.Other private expenditure

Out-of-pocket payments

· · ; Vietnam Living Standard Survey

Year No of HH with No of HH with income and expenditure data

expenditure data 2002 30.000 45.000

2004 9.300 37.200

2006 9.189 36.756

2008 9.189 36.756

Public vs. Private health expenditure

L.._-- ---··-·-·--·-.. :J

Objectives 1. To investigate catastrophic and poverty

impacts of household out-of pocket health expenditure in Vietnam

2. To identify socio-economic determinants of the impacts

3. To suggest policy considerations

? -Methods

Key fmdings ~

~

Pattern of catastrophic expenditure and impoverishment

2002 2004 2006 2008

n .,. n .,, n .,, n 'lo

catalO 5,325,19 30,8 15,~4,426 33,9 ,419,4~ 1 29.9 6 ,!l.:tl,BJI5 31.7

cata20 ~"''·~' 15".0 l,280,Hi7 :1:7.6 3,197,14 14,1 l,lEID,690 16.1 • cata30 1,43'5,719 8,3 1,903,326 10.2 l,a1!2,4 ... 2,02B,348 9.7

9

C!ta4D 8'11,4'39 4.7 1,055,910 5.7 1,096,17 5 .1 1,151,5CD s.s 7

1m poor 590,~6 3.4 769,505 4,1 667,863 3.1 742,587 3,5

Impoverishment by location

• Urban • Rural

5.2%

2002 2004 2006 2008

Annex4

Amount of out-of-pocket health payments made by a household/month

200 -

(Among ths households fhar paid fot h~aJth c¥e diHing !ha/asf 12 monlhs) (Unfl: VND 000)

2002 2004 2006

10.7US$

178.2

2008

Catastrophic expenditure (using cut-off point 40%) by location

2002

• Urban • Rural 6.6%

2004 • 2006 2008

Catastrophic expenditure (using cut-off point 40%) by expenditure quintiles

W1stquintile •2nd quintile a3rd quintile •4th quintile If 5th quintlle

7.8%

2002 2004 2006 2008

Annex4

Impoverishment by expenditure quintiles

•1 st quintile • 2nd quintile • 3rd quintile t4 4th quintile ¥;5th quintile

12.1% 11 .1%

2002 2004 2006 2008

SES determinants

C~ta40 Impoor 1. Had more elderly 1. Had more elderly

people people 2. Were living in rural 2. Were living in rural

area area 3. Belonged to the 2nd

quintile

Health insurance had limited impacts

Policy implications 1. More attentions on health care and financing

for health care for disadvantage people (the poor, the near poor, the elderly and people living in rural areas) are needed.

2. Develop solutions to strengthen medical cost controls

3. Expanding coverage of health insurance in Vietnam to enhance impacts on financial protection (the depth and the breath of coverage).

Socio-economic determinants

ex of household head household size number of old people number of children <6 urban/rural no of hh member with insurance card region expenditure quintile

Health insurance

Limitations

• Original datasets are not available • The way of organizing data are not

consistent over the years • Difficulty in merging and using utilization

data • Difficulty in breaking down the oop by

detailed items

1ll~P-1~ (Contents) It 'lfJil:!)-tH

• llil~!!fll{

' Jl1:.'tt!J " Jl1:~i!fi'J<¥

., ljif;t"i* • li!"ti'JI3Q~ " l1il~ti'JJI!i!l •• 1/f"H.*Ill!!<

· - ljif;tf;ill! " J!1:!/l9}1'J!!l · - fli~!!lffJl1:i\9!!l • :lotttll1:.'tt!l •- li>!liillHHif " lill'l,tl!!lQllk:Eil!lit

.. i'iii!

• ~WHOlil#lBti<WIJCATAlo~~

~1;tll!l:ltf1i:CATAitmtli'$i

j:;,litr'lfillilri'f'!ii'lf: r WHO! lODS Ioiii.~ :001

12.20/o l l:ifl l 1.008 9.2..,. l003 10.90/o

r ~~~~m*~~. ~A~~~

j::, l!l40%ik'i!i'il-ll[, 2008o!f­

CATAili'f'2003o!f-

• ~l'llfilli!'>l!$iilri• ~~A-~:tlfl=

1ill'll':-"!:itlflH<'i!i%~&i!!lt!l<lli<

"' Introduction ~"· The state backgroul'\d a: Health expenditures li'.: Health financing and reform

L Research Method c: Objective f", Data Resource n·: Study Method

g Research Results a: Utillzatlon < OOP ~··. CATA 11: Poverty causes 1: Impact Factors

til Discussion

If measured by WHO & China poverty line,_ results of CATA varies greatly

ltC WHO: 2008 14.00fo 2003 12.2°/o a:: :ftDUl, 2008 9.2°/o 2003 10.90/o

Income disparity widened with rapid economic growth, whether 40% is appropriate or not, CATA is higher of 2003; Very high saving rate in China, Total income-total expenditure=savings; whether expenditure can reflect real situation of China?

W~: ~~~~tt~~~lli~~~~~ Discussion: Major Influencing Factors for CATA

" li<:.!it.Wl: 1t;ll;;llo~it

It !i!Stl!i'l!:lo.!a**ll!l

" !lllil;IJ<'I', 1t;II;JHIM " 7::m~tl'1. 1t;ll;tti!JU~>ff

" l!!f-171Jii:"'7.K'I' " tEtt®tt:i:l!lrutl!i\'1'. l!liilfl'l

iilll'fi'Jil1Hll. OJI!ff!tlll!llt • tt!i!Jt• 2005-2010 JllmT

50%

*social economic development and household structure Education level Household income level Family structure: esp. aging

Health demand and utilization Disease: esp. chronic disease Inpatient treatment

Level of Medical Insurance Rapid expansion of Ml, may results in limited protection & stimulate demand; Hospitalization rate increased b 50".4 2005-2010

Annex4

w~.x~tt~~~ilim~~~~~ru~ Meaning of CATA & its Measurement

1: f.itii(l!J~)(, ~~&I!HI!llll<

liliitiiJilt!ff~J!l~l!.'l:jti!J, It~

f!k/S, r.Jii'tA'Ifllil~:fl!lt!IIKraJiiT

lttt

J!; r.iti<PJ~ii: :ttli<Filil~. ~ Al;;:;tl!Hl!~. 1t;ll:JeJ!~:;tll!

~.@.~Jl!fi(J;l:!l;tt (i?,jii<JI:,)

Significance : Objectively reflects impoverishment from medical treatment;

Sensitive and comparable : Data easily available. esp for developing countries

Iii f.itii(l!Jtii~: !llft.Z.~fi(J~J11

$!:~!:~"'~*' 4cotoJ;;~~'!tm I&

If Adopted different criterion for poverty line and level of threshold, results will be different substantially

w~. ~~~m~~~~#i1-~~~~ Variation of CATA resulted from different

measurement 0 !iWHOJ11;jj'J11-. )!l,ao!IVJQ,a:;t

IIIJt»Jlt:IJCATAi!,J!-~;1;;,

J, tiftll..ti:X:IiS20DB!f:jl}14,00fo (lil,llJ:!'iJ 11,3°/o, 15.1°/o)

" !illll<r.tl!l~;m. m~Jtlll>t»Jw jii:CATAli!#ll!:ot~'l':

t tti:l!ftl!l.l:tl::l200~:'39.2°/" C1Jlltfj;] 7.0%. 10.211/o

7.0..-~t. 10.1'/o .

• ~~~~~;t-jll:~~. ~;!;~& Pt{~!ii!IIWHO:IJIIilUf:CATA~ItiN. i!ii lil!lllli;ll:l.tl!l!tit"'~l•Jaait

1U!I.w!.I..W~!Wults of CATA ~al;IUncome or e•nt:n_dllY!!:, will be varied cr~~Y.i

-Calculation based on Total Expen. • 200814%( Urban 11.3%;rurall5.1%; -Calculation based on Total income

CATA 11.8% (Urban 9.5Y.;rural12.5%)

If adopt China povertv line· CATA calculated on jncome and exp~ CATA variatjpn not big

--Expenditure based calculation: • CATA 9.2% (Urban 7.0Y.;Rurai10.2Y.) -Income based CATA:9.1Y. {Urban 7%;

rurallO,lY.) The variation of Latter not big

Annex4

~.,.,,...

t:~

::::--.·

Financial burden of Out-of-pocket expenditures and

Health facility utilization inLaoPDR

By Dr. Manithong Vonglorkham National Institute of Public Health, MOH, Lao PDR

> Total population of 6 million (estimated wo8)

> Growth rate of 2..5 % per year > The population comprises 49 ethnic groups > Over 70 % of the population lives in rural

area > The adult literacy rate is 73% > Life expectancy at birth is 59 years for males

and 63 years for females > MMR: 405 /loo,ooo LB > IMR: 70/1,000 LB

• Sourct: NSC's Wt"bsite, Cuuus 2005

=------~~ Health insurance schemes in .lao

~>Civil Servant Scheme (CSS)

•Social Health Insurance (SHI or Social Security Office)

•Community-based health insurance schemes (CBHI)

• Health Equity Fund

• Private health insurance

The insurance covers around 10% of the population

@Background

@Objectives

@Methodology

@Results

@Discussion and Conclusion

Background of Lao PDR

}>GDP per capita: 882. (estimated 2.oo8)

>-GDP growth at 7.6%

>-Government spent on health less than 1% of GDP >-Average health care expenditure per capita 34 US$

> 63% from OOP

> 21% from government

> 16% from donors

)> Hospital income depend on user fees

• Source: NSC's website and WHO (National health Account Database, zoJo)

~~,~~ -

Objectives

• To provide the trends in health service utilization and the evidence of household financial burden due to out of pocket health payments

• To describe the determinants of utilization and catastrophic health care expenditure.

Dissemination workshop of study results the financial burden of health payments

23-24 March 2011 Manila, Philippines

COUNTRY POLICY BRIEFS (Group Work)

• Introduction - Is the country and health financing context

succinctly summarised? • Study summary

- Does the policy brief highlight key results from the study?

• Policy implications - Are viable policy options offered for improving

financial protection against the costs of care? - Are broader policy implications assessed? - Are options for working with partners detailed?

Armex4

Annex4

POLICY BRIEF: Cambodian Health Financing

Key Health Financing Schemes

;. User lee• syste#l. with exemptions for the poor, but in practice th• propo[tion ofp•tients reeeiv.,_g exemptions reDUioined.low (mostly o.t hospi~l I«Vel)

).. Ina-eued number of poor protected byth• Hu.lth Equity Fund• (68% in 2009to77~of those who 1re livingunderth• Motional poverty line in 2010)

};- 12 CommwUty band health ineurance schemes covering over 70,000+ populotion.

> National Social Security Fund for private u ctoremployees (wnrk injuty coverace of 300,000+ membus)

;. N01tional SodU Se curity Funds for Civil Sltt\l'antwilhlutw-e elq)Qnsion to coYuheallh

The Rectangular Strategy and National Strategic Development Plan

Cambodia Health Financing Performance Indicators related to Health Financing Strategy for Asia-Pacific

KEY FEATURES OF STUDY Areas of analysis:

+ Inddence of illnesses and health care seeking pattern + Choice of health care providers + Health spending and debts • Impacts from health spending including catastrophic health payments

Data sources:

• CDHS and CSES are the best data sources for supporting policy + health care utilization patterns • financial protection against health ca;re costs

+ Cambodia Demographic and Health Survey 2005 (n = 73,010) , Cambodia Socioeconomic Surveys 2004 and 2007 (n= 74,719/17,439)

Analytical methods: · + Descriptive statistics altalysis • Catastrophic and impoverishment analyses using WHO Methods

KEY FINDINGS

20%

0%

Significant improvement in

+ Health care access ill people seeking care more higher use of health centres among lower economic groups

+ Financial protection lower OOP share lower impoverishment and medical debts lower catastrophic households

%care at Health centers

• 2004 • 2007

"HiP,.eruse of health c:ent~rs especially emong lowr.st quint:il.es

Average OOP per capita by type

r=-= ~:._~--··-·-· · .. --_·-· ------~·--=-~·-·-_·-_--! ~.:m

l ::r-------------~~.-------------~ I .. ~+"· .. ~~....,.......... ............ ~~ 1. __ _

Higher spendinr; by~ ww:ier 5 and elderly. and JUshu economic quintiles

.........

~~ l:j:l·tlfhii

Annex4

% Ill individuals NOT seeking care*

Average o o P per visit by type

catastrophic Health spending 10.0%

9.0%

8.0%

7.0%

6.0% r 5.0% T !Ia 4.0% JJ

~ 1--- 1 -

;_)\

3,0% _w_ r- 1--- ~ - -~

2.0% fll= t- ~-~ ~i

...-- c.i l .O% t- ~ '--~ .'2004

0.0%

I I I Ill I IV I .2007 II v

All Quintile

Annex4

Policy Implications

<I' Proportion of households with debts from medical spending decreased

5.3% (4.9r~5.7%) in 2004 to 4% (J.4%-4.6%) in 2007

<I' Proportion ofimpoverishment from health spending decreased

from 3% in 2004 to 2.5% in 2007

<~'Proportion of catastrophic health spending decreased from 6% (5.6r.-6.4%) in 2004 to 4.3% (3.6%-4.9%) in 2007 + Rural areas more likely to have catastrophic health spending

Policy Implications ./Addressing weakness in financial protection especially among the

rural populations

"Expanding Health Equity Funds coverage (breadth & depth) to cover all poor + Hannonizing core benefit packages of Health Equity Funds

./ Exploring options to increase coverage among non-poor informal sector: • What are the roles of Conununity Based Health Insurance

schemes? • HO'iv-to ~ystematrcally integrate various ongoing approaches

towards finoncial protecficm for non-poor informal sector and towards wllve:rsal covcrL\ge:?

• How do we pay for it?

Policy Implications Many possible contribudng factors to such improvement:

• Health care services more available, and better access especially at health center, road infrastructures development

increased financial protection from Equity Funds expansion between 2004-2008

+ people get more incomes as seen in higher capadty to pay-aHordability to pay

However, there are still remaining chaUenges

Equity in health care access as shown in variation in utilization

proportion seeking care much lower among lower quinliles

proportion receiving inpatient care among lowest quintile only half of highest quintile

Rural )1ouseholds have hlgher catastrophic risks

Potential rise in health care costs and financial burden MV-~H"J'lol·ft181•"-Vulaf.l4h."""' ~, n.,,_,.n-_,rii~P<I~ ..

Keqin Rao Lu Ren

·:· ~:ll:i!i!i#~ffill:ll-U~Jt --i::~l'!~;

·:· ~»mi!i!i#W;i4!ilit!Jii -~.tiP P.X;;

·:· {l!i::i!l!ilit.:P.~Ua:*.PH~­:I.il.tJP~lHE:

·:· ~*0~.:P.1o~a:*:l!8~ {t-17;!;:0~.:P.1o~a:*:

•!• :t£~0:lz:~ll.lti¥.J0&tt­ll*fLHM~1'f::9

=:::-Set up basic meaical insurance system-universal coverage;

•!• Implement essential drug policy---Zero drug mark up ;

•!• Establish grassroots health service delivery system­enhance accessibility;

•!• Realize equalization of public health service;

•!• Enhance public hospital's awareness for public-be reducing profit Seeki behavior

Annex4

:&!£~14%, it!i •!• Incidence ofCATA 14%(2008), , :&# (15.1%) higher than 2003(12.2%); rural

(15.1%)Higher than city (11.3%);

•!· Impoverishment rate after -oi~~ hospitalization 6.8%, rural area a: Is markedly higher than

"~~ city(2.2%);

"'4rl!l,;;<,iflffli1]U~;t§J/J~ •!· Rates of not seeking medical _-10.6%. 21.5%. ~jf~W,I!if70%~~ consultation and hospitalization

10.6%, 21.5% respectively, reasons for not seeking: 70% due to economic barrier;

·~ Despite rapjd progress of universal coverage-barrier still existed; fin~nclal, physical accessibility s1111 have spaced to be Improved;

~· Substantral increase in u61fzaUon ofinpali ent service, but need to lntnrpreted with caution;

Annex4

Eliminate mar k up drug prlc e of hospital (15-20%) liXWff!i~$11$

All drug listed in the list will cover ed by insurance if#Bi#HHtUmm

Centralized purchase & distribution of dru g through bidding jf!t\!Jilti!lflj!j, lij',i;l;

Extend essential drug list use to all public hospitals IE#~lillHCii lli=lf:i} JtJIDlt

En~~~~~:-!ltll!<lnfut Payment reform

U;&#lt<J/lf Eliminate drug Mark up price I

liXI'!filj,P,Jrru;t _

Strengthen gove~rn nt /,------Regulation role / Enhance quality ru{.l:tfff!ll:'lfl!!lfll!- ~ ~urance system

., __ --~---~MI!l;S:. Jli,-Mft''<i!~ Operation

(-) Partnership within gover

\ epartment of Finance \

---- . \

Labor and social Insurance "j ~-- Bureau ----z ,.. I

Civil affair Bureau . ./ / I ' •

Incorporate Uac strategy into n:1tionnl soc1oc.conomlc

/

{_/~ '

Collnboratc l'ith all stokcho1dcrs & portncn

·' , - 1~~~'Ht~•·;Yoi= :01 .,,_

Dr Bouaphat Phonvisay MoH Lao PDR

24 March 2011

Lao country profile Key data

• Population: 6 million - 86% of the population in the informal sector (LECS4) - 27% of the population under the poverty line

GDP US$ 882 per capita (2008) GDP annual growth rate: 7% (2006-2010) OOP: 61% ofTHE GHE: 0.7% of GDP Life expectancy 61 years (Female 63, male 59)

• IMR 70 per 1,000 live births (census 2005) USMR 90 per 1,000 live births (census n2005)

• MMR 405 per 100,000 (census 2005) Utilization rate: 0.4 visit/capita/year

Health System reform in Laos I Empb)'i=r ~ I .I SSO.

~vm-.t

rJ SASS

--l Government I CDHI ..._, HEF

-.,,.,

'~:-·----------- ---~~ ,...:-"--'!.._.._, r-- i Private CllnlcJHo;pital

I Popul~ ........... .. J.. ... j Privale Pharmacy L/ Patient l 4 Public Hospital

MOH-WHO Co-opll!'at!otl Ptojecl

~

r f-I

Contents:

• Country profile

• Health care financing arrangement

• Study summary

• Policy implication

• Discussion

- -111IWil:OCj..tlllfJ'.£0t!

Annex4

• Before 1995, all services publicly provided and financed

• User fee was started in 1995 • Financing sources were diversified (user fees

and social health protection) under health care financing reform and arrangement

• The private sector also began to play a role in health service delivery especially private clinic and pharmacy.

Health care financing. arrang~me.nt in Laos I D~Us .sASS _,~o CIHI :11il'

M!Disterial MOLSW MOLSW MOH MOH utbority mpll!.mrul:ll.rion 200_6(~ 200~ 2002 2004

d.!• <chmu>)

e£11 PMDca:ee PMDecreo N•.m.al 1\opl&doo ~~o:r\AI (Compulsory) (compulsory) (MDII) rq:W_OIIonbut

(mhmtary) ptOJoabual arget .POp_uladon CiVil $1%Yimtl + Pttrlllc IDd state Non-~ self- houseboldi

d~ cwn¢c:uapri.to" ef!JP)Oyed+ 1dectifiecfas poor m~playea+ dependents ~-"',OO"'tr

~mated number

m~~=' 386,988 Abouilmlllicu Aboat I 6 milUoa

fpersons In the persO.is' p<nOIIS ~'l:el popolatlou <lllliro.} >od p.u:;.

... lhdt ~)

ovtr::i.g"e {average 317,000 ros.ooo 140,000 17-7,000 010)

~e:a%of 71WO '2111 s': !I~ tarzn..!_~lptl"

. Ov.l!!r'.<i&e as% of

--~ -~-

Annex4

• Health seeking care:

-Seeking care at facilities

14% (2003-2004 and 2007-2008 respectively)

• Disparity of access to health facilities

- Central hospital: richer and urban pop

- Provincial and district hospital : Poorer and rural people

• Do household face financial burden through health payments? )> OOP increase

- USD 2.5 (LECS 3)

- USD 4.3 (LECS 4) )> Catastrophic incidence:

2.5 time higher than average for poor

Reduce OOP pnd lncreas_e utilization

~ Increase public expenditure on health

• Domestic sources: ·~armarkedsin taxes • Nat~ralresources

•Strengthen revenue collect ion

JJ. • External sources:

•Mobilize f unds •But alsci improve aid effectiveness: sh1ft t o programme and sector basee

• Whose health service needs are not met?

- Utilization is low for all quintiles

0.5 visit/cap/year: richer

0.3 visit/cap/year: poorer

1 visit/cap/year: SHP

~(i_u!ilciOI& i

• Reduce OOP

• Increase utilization

P'ii'SilJi!S • Extend SHP coverage: • Special intervention for vulnera_ble • Increase govt subsidies

• Improve quality of care • Increase productivity

THANK YOU FOR YOUR

KIND ATTENTION

M ain ina icators or~tn1"lttC1ITClng~ 2000 2005 2006 2007 2008 2009

~ol-io GOP <(.6~ l~ l3% 3.411 ~

HE:mtilMNT 46,861 B3 726 1113 13 155 400 2n.<!11

b<_ oi!i1o PilE . MilT '"'"'' '32.Ul .ooli> """' 71.$!! !An~ond~a •"'urcn.::

~uh:ztl 74~ 59!1 T.W m 7911 Sl!1 2!l~ :If>% 23".1 :1()~ 18~

Oh< 6~ 5lt ·~ ':w .3'!1

PHE-b ff'WII of cv•;

To~""""""- 2311 ' 21% 21~ 'l:l'fl : ' 21 '11

Secanoia!vil<•11h- 29% 32% 32'll 421 31' Prlmor,l>oolll·,_ IllS: 22'1. 23\1 29!1. 2~11 Ofuir """ 24o/. 2A¥ 2% 2'-'J.

Results summary

• HSES 2009 results show that 29.1% of households have made some out of pocket payments on health services.

• Further, the analysis indicates also out-of-pocket health payments (OOP) take on average 3.2% of total household consumption expenditure.

• Out of pocket health payments are on average 5.5% of the households' capacity to pay.

13'11

200.42

fqJ

7~

m ~

·22ll

m 24% .23%

Annex4

Per capita GOP $1,669

GOP growth 6-8% Male 48.9%

Female 51.1% Consumer price 4.2%

Urban 62.6% index

Rural 37.4% Budget overall ·5.4 balance to GOP

IMR (1000 live births) 20.0

Foreign trade ·252 MMR (100,000 lives births) 89 balance,

min USD

Overview of health financmg m .::fl

ongoua Financing sources Mix of gen,eral taxation, public health insurance and out-of-pocket and services payments overed

General taxation funds: Primary ho5pilals, Public health nterventiOns and fixed cost of secondary and tertiary level hospitals.

fiealth insurance covers: Hospital inpatient and outpatient services

OOPs for tf1agnosls and tests, private hospitals, copayments for npatlant care at public hospitals

Service providers Mix of public and private health care providers

urchasing Population based resource allocation to primary health care rovlders Case based payment for secondary and tertiary level hospitals

Results summary

• The share of households with catastrophic health expenditures was 3.8% of the total households. " total 23488 households have experienced the ·catastrophic health expenditures in 2009.

• Out of total households, 1.8% was impoverished due to health payments. "This accounts to 10855 Mongolian households in 2009.

• The health service utilization has been fairly similar across most quintiles except the poorest population.

Annex4

• Health financing strategy of MoH (201 0-2015) and on-going amendments to Health insurance law has objectives :

To increase health service coverage of population by increasing the HI coverage, especially for poor and vulnerable To expand types of health services funded by health insurance and state budget To increase the overall allocation for health sector from government expenditure

Broader policy implications-macro/natior'falltwel-u

• Strengthen the SHI based health financing model by improving health insurance system:

• Strengthen the capacity of SHI as a purchaser by ensuring independency of the health insurance agency

• Extend population and benefits coverages of SHI by increasing government subsidy for the poor and informal sector.

• Gradually pooling public financing sources to HIF to effectively purchase health care services using greater financial leverages (reduce cost, improve quality)

• To increase public financing and investment: • From mining revenue

··Ensure pro1eci16h-tor mosrvuttaera population groups

• There is a need to improve the policy to ensure health service utilization by the poorest of the population by eliminating access barriers: o Accessibility should be improved (ADB is implementing 2 projects with

MoH), strenglhen secondary level hospilals o Improve HI coverage and insure especially the poor people (state subsidy

targeting and increase of subsidy) • Free essential drugs and medicines at primary level and oulpatient essential

drugs should be covered by HIF at secondary level • Not only poor, but also rich should be protected from catastrophic heallh

payments o Insurance package should include health services provided by private

hospitals in Mongolia o Encourage the better-off people to enroll in private health insurance • Improve quality of health services of public hospilals

,... . -. --., - --- - --- - ~ -- - .. Options for working with partners

• Further improve the catastrophic payment data availability and utilization and strengthen NHA (MoH,WHO,ADB, World Bank)

• Improve intersectoral dialogue (MoF, MOSWL, MoH, NSO and civil society)

Burden of Health Payments in the Philippines

Rouselle F. Lava do, PhD {Philipp/n~ Institute for Development Studies) Valerie Gilbert T. Ulep, MS {Philippine Institute for Development Studies) leizel P. lagrada, MD, MPH, PhD (Department of Health) Virginia Ala, M.D., MPH (Department of Health) Israel Pargas, M. D. (Phil Health) Rosario Vergeire, M D. (Department of Heallth} lucille Nievera fWHOl

OOP has increased in the past decade and share of SHI in health spending remain to be lowest among all financing

1995 SourctsofFunds

....... ~

Total Health Expenditure is Php 87.18 (3 .6% of GOP)

sources

Source: Philippil"'e National Health Accounts

2007

Total Health Expenditure is Php 225.8 8 (3.7% of GOP)

Higher admissions in the richer population

Proportion of the population who had any admission in the last one year

• Public Hospital • Private Hospital ~AU inpatient

Source: 2008 National Demographic and Health Survey

Annex 4

Philippines

• Increasing domestic economy despite global fiscal challenges

• 7.3% Growth (in GDP) in 2010 and anticipated to grow by 5% in 2011

• But inclusive growth on social provisions for the poor like health care remains a challenge.

Problems in Health Financing: Fragmented health financing system

Type of facility for outpatient visit depends on capacity to pay

• Public Hospital • Private Hospital II Public non-hospiul • Private non-hospital II other fat.1litles •All outpatient

Source: 2008 National Demographic and Health Survey

Annex 4

Higher admissions in the richer population

Admi!ision in the last six months

• Public Hospital M Private Hospital ~All inpatient

Source: Annual Poverty Indicator Survey, 2007

Alternative for inpatient utilization

Proportion of households with hospital charges expenditure

• 2000 • 2003 8 2006 • 2009

Source: Annual Poverty Indicator Survey, 2007

Higher outpatient visit in hospita s compared to non-hospitals (clinics,

RHUs and BHU) Quintile share of outpatient utilization, by type of facility

Wealth QuintJ1e

•Hospit:J.I Public •Hospilal Pri\--ate •Non-hospital Public t::Non-hospital Priv3.1t

Type of facility for outpatient visit depends on capacity to pay

~..,~+ oo"e4- _,..,b

q0

o"t:; ...,~bq

• Public Hospital • Private Hospital

• Private non-hospitals Other facilities

Source: Annual Poverty lndic;~tor Survey, 2007

;& Public non-hospital

e All outpatient

The public-private hospital system led to defined fragmentation of patients

according to capacity to pay

.. Quintile shares of lnp01tient tare utilization, by type of hosplt.:JI

""'"' Wealth Quintile

• Public a Private

Burden of Payments [OOP/X]

8_0%

7.0% ..,-----.----

60%

per capita disposable

income

Per capita expenditure

~ Percapita Capacity to pay f

r discretionary expenditure

a Poorest Ill Richest w Philippines I

The low catastrophic payments among the poor may suggest health

care inaccessibility. Proportion of households exceeding 40 percent of their capacity

to pay

u ------------------2.0

1,&

poorest poor middle rich richest Philippines

• 2000 • 2003 • 2006 • 2009

The Dimensions of Universal Coverage

Towards universal coverage

1:. $1t:.dt.Ke ~n sti~ II\C ilr.d f~u ~

~

Onlylnp.Mknt

Sol!rte: D~vlllfo'IU'II,WHR2010 3"'-l52"116"?ofPopulltlon

Financial Risk Protection

• Increasing the height -Shifting to case payment and no balance billing

mechanism

- Ensure fiscal sustainability of Phil Health by imposing price and patient volume controls

-Adopt clinical practice guide (CPG's) and co­payments to avoid unnecessary admissions and introduce mechanisms of cost-containment

Annex4

The extremely high share of medicines on the total out of pocket is alarming

Distribution of out-of-pocket he~lth expenditu~ components, 2009

Poorest Richest

•Medicines • Hospital Charges

a Medical and Dental • Other Medical Goods

• Other Medical Sevices • Contraceptive

11 Food SuppleflM!nt

Financial Risk Protection

• Increasing the Breadth - Better targeting of vulnerable population (Ql and

Q2)

-National government to pay for the premiums of all households in the SP. The responsibility of local governments can then be shifted towards enrolling the informal sector.

-Craft policy that captures more informal sector in the safety nets.

Financial Risk Protection

• Expanding depth -The need to strengthen the OPB Package of

Phil Health including drugs

- Benefits that contribute to the attainment of the MDG and mitigation of emerging non­communicable diseases be enhanced.

-Information campaign to improve utilization

Annex4

Number of DOH Licensed Hospitals

GOVERNMENT

-· -1-3 ~ 4-6 . I 7-to -11-29

. , --"-• -· -1-3

tm 4-7 i I 1-11 -1!1-64

PRIVATE

Barangays with Botika ng Barangay in Marinduque

•••

....

Does the Philippines have fiscal space for

health?

Overall fl..c.at •4'&ctt nc;:rc~uelilo'J % ot GOP)

Adapted from Schieber, 2011

Distribution of Hospitals, by Level

Strengthen Supply side

Strengthen the primary health care system - RHU and BHS should have the capacity to treat simple cases and

should act as gate-keepers in order to decongest high level hospitals

- Assignment of members to specific facilities Respond to the scarcity of health facilities in rural areas - Ambulance network for emergency medical care - Harness use of tT to improve access (i.e. TeleHealth) - DOH should start crafting an investment program that takes

into account 1.2 million Filipinos born every year. • Increase the capacity of public hospitals in the Philippines

to ensure fiscal sustainability and quality of medical care

Creating Fiscal Space for Health

• Restructure existing laws on sin taxes

• Promote expenditure efficiency

• Consolidation of donor grants through the Sector Development Approach for Health

POLICY BRIEF CATASTROPHIC HEALTH PAYMENTS AND

HEALTH FINANCING POLICY

Hoang Van Minh, r-'JD, PhD Hanoi Medical University, Ha Noi, Viet Nam

& Nguyen Thl Kim Phuong, MSc

World Health Organization, Viet Nam

Manila- March 23-24, 201!

•!•Population: 87 million

• Rural population: 74%

·:· GDP growth rate: averaged 7.5% until 2008, recently reduced to 5-6%

·:·GDP per capita (2010): 1,200 US$

·:·Current macro-economic turbulence; high inflation rates, high food price

·:·Challenge: families that have left poverty do not fall back Into poverty

Total health expenditure as % of GOP (2002 - 2008)

~ of:: .,..-

lr-~ 1-

~ I I .

I ~ - ~ 1-- 1-

I~

~ - r- 1- - ,_ r- -

I~

'"' , ...

Contents * Country context ¢ Study summary -$ Policy implications

Health sector key reforms

Annex 4

Before Health system was purely fundeli by tax, based on a strong primary health 1985 care network dosely linked to hospital system, universally accessible to all.

1989 Legalized collection of user fee at public health providers; legalized private 1\ealth practice and pharmaceutical market

1992 Introducing health Insurance schemes, compulsory for salaried workers (mainly Civil servants) and voluntary for school children; user fee exemption for the poor

2002 Esrabllshlng healtl"' Cllre fund for the poor (Decision 139/2002) Issuing hospital finllnclal autonomy policy (Decree 10/2002}

2005 Free healtl'l care policy to under 6 children {Decree 36/2005); Full subsidy for the poor to enrol In helllth Insurance

l OOG Granting greater 1\ospttal financial autanomy (Decree 43/2006)

2008 Passing the Law on Health Insurllnce (In effect from July, 2009); full subsidy for children under 6 to enrol to health Insurance. Road rnap to enrol entire population from 2014.

Components of health expenditure (2007)

Other

Annex4

Health financing trend

SO%

50% ....

Health financing 1999-2008

, .... _ 20%

10%

0% ~9110 2000 :OQt ?004' *3 2004 20C5 2001 2007 2008

e :t

1110DA cPr~t>Jnclal budget

oCentral budget

QSHI

(;30ul-of-pockel

oOth• r Pflw.Le $1JII!IrdiBQ

Study methodology

• Using WHO developed methodology • WHO/ Ha Noi Medical University as

investigator • Using data sets from GSO household

surveys for 2002, 2004, 2006 and 2008

Finding #1.2. Who are they?

Most of them live in rural areas. Percentage of households affected with catastrophic payment in rural area is doubled than that of urban area- around 6% for rural area compared to 3% in urban.

Catastrophic payment tends to disproportionately affect the poorer population. For instance, in 2008, percentage of households faced catastrophic payment in poorest quintile is doubled than that of the richest quintile.

Households more likely face with catastrophic health payment if: - Had elderly member (all years) - Had young under6 children (all years) - Resided in rural area (all years)

Study on catastrophic health payments and impoverishment

To find out: 1. How many people faced with catastrophic health

payment? Who are they? 2. How many people became poor (impoverished) after

paying for health care? Who are they? 3. Can health insurance coverage protect patients from

facing catastrophic payments and impoverishment? 4. Is financial catastrophes and impoverishment

improving over the years? 5. Are there regional differences?

Finding #1.1. How many households faced with catastrophic payments?

Between 2002- 2008, overall, 5-6% of households, i.e. 1,100,000 households or4.5 million people, faced with catastrophic payment due to health payments. This level

didn't changed much over the years (table 1 ).

2002 2004 2006 2008

No of HH 811,499 1,055,910 1,096.177 1.151,500

%ofHH 4.7 5.7 5.1 5.5

Finding #2.1. How many people became poor after paying for health care?

Between 2002- 2008, overall, 3- 4% household, i.e 700.000 households or 2.5 million people, were dragged below poverty, due to

health payments

2002 2004 2006 2008

No ofHH 590,446 769,505 667,863 742,587

%ofHH 3.4 4.1 3.1 3.5

Finding #2.2. Who are they?

Households that were more vulnerable if: - Had elderly member -Had children under 6 -Were living in rural area -Belonged to the 2nd expenditure quintile

Finding #5: Are there regional differences?

Among 8 social-economic regions, three regions of North West, North Central, and Central Highland are the regions bearing significant higher rate of catastrophic payment.

Policy implications

• OVerall Vietnam already spend 6-7% of GOP on health -quile high compared to countries of similar Income, but hasn~ achieved universal coverage yet. The issue is not to raise the level of tota l health expenditure but the share of public spending in it, and make public spending replacing OOP. It's important to expand HI coverage, especially to the most vulnerable population, namely elderly, children under 6, the near poor. ll's equally Important to make HI capable of protecting f!70~ Ie. The current contribution rate Is already high \4,5Yo workers income for individual coverage), further Increase is not foreseen. The only way to reduce OOP is to use existing resources more effectively and more efficiently.

Annex4

Finding #3. Can health insurance coverage protect patients from facing catastrophic payments and impoverishment?

Analysis showed that having HI entitlement can reduce OOP but not that much that it could protect the households from financial catastrophes and impoverishment

Finding #4: Is financial catastrophes and impoverishment reducing over the years?

Percentage of households faced with catastrophic health payment or have been impoverished didn1 change over the years

Important conclusions from the study

• Health utilization? • Percentage of households facing

catastrophes and impoverishment was high; didn't change over the years;

• elderly, the near poor, under 6 children and people living in rural areas are most vulnerable

• HI status had limitted impacts on didn't financial protection

Options for expanding HI coverage to vulnerable groups

Using government revenues to provide full premium subsidy for 60+ elderly and the near poor(fiscal space?)

• To move from individual to household coverage, to cover dependants. This help to broaden contribution base, Instead of contribution rate, and make HI financially more sustainable

• For informal sectors, flat premium, adjusted by household size, possibly partly subsidised by the gov

• Measures to enforce complaince

Annex4

Benefit package

• Current BP is very broad, covering almost every service being offered, without emphasis on cost-effective services. Cost effective BP often favour the poor.

• But the co-payment rate is ranging from 5%- 70% (depending on type of services and level of care)+ capping on max eimbursement ceiling.

• Need to revise the BP

Options to reduce regional disparities

• Mechanism for risk equalisation across provincies (fund allocation based on social-economic factors and epidemiological patterns)

Glossary OOP Public expendiiUres on health Private expenditure on health Total health expenditure Providers direct budget subsidy Health insurance expenditure Co-payment in health insurance Catastrophic expenditure Household subsistence need Household effective income Household capacity to pay Impoverishment Expenditure quintile Benefit package Provider payment mechanism Cost-effective services

Options to reduce OOP and better use of existing resources

Using provider payment method that is promoting quality rather then quantity Monitor providers and health service users to prevent over pricing, over provision Regulate medicines prices Apply co-payment strategically. so that it does not disproportionately affects the worse off. Flnd Innovative efficient ways (better primary health care, integrated care, instead of hospital-based care) to address health care needs of elderly people. Improve transparency of system

Partners

• WB, EC, UNICEF, WHO, GIS, NGOs • Government • Support:

-Technical assistance/ Policy advice -Funding/ financial support -Research and training/ capacity building -Coordination- consistent ad vices

~~@!ru@O C::O@§iOrnifu !huu~{[lffulfil@® lPLP©@lTrg}l1iiii ®fJ ~)f®OO~ c/ ©uu~®'W~uuutiim mJtm

~~ruoo~D®W@®§ March, 2011

National Health Insurance Corporation (NHIC)

__ _________.... 0 Soc1al secur1ty system

-----------------------Sotlal Security System Qf Korea :

.:. ...... .. . . ·-~~..___:.:,;~

•M"'k•IAid I • B"icUv<llhood Prot«tiooj • Wethre for thP! E1derf)t

• Wdr,uc. fGrU.!. Dls;~bf~

• Wflifl"re for dtnct~

• Wdhre for Worne11

• HejlcarOI P.q"(:hblrk SCt.ltl

Work

Annex 4

Ir Overview of Korean Health Insurance System

II. Outcomes of the Health Insurance

III. Challenges

"9; Growing demands based on economic growth

:~Strong ~ublic support

'If' Strong political will

''ii? Step-by-step coverage extension strategy

Annex4

(HIRA)

Public, Independent, Non-profit organization

An entity to ensure or assess quality & cost

effectiveness of health care and review claims

o Employee: 5.64% of labor Income (in - Employer & employee pay 50%

respectively o Self-employed: Based on scores

on gender, age, income, property, car, etc.

:9',· 20% of expected contribution revenue '!'"General tax (14%) +surcharge on cigarette

:_~ - ·- ·.~-.~-.---~·· 0 Operational structure

i;l; NHIC

"' Public, Independent, Non-profit organization

"' Single purchaser for insured health services

• Under the supervision of a Korean Ministry

• Central agency (govt. agency)

- Runs a general hospital with 745 beds and 24 clinical departments

'!11" 96.6% of the whole population (49 mil.)

- Employee insured (63.7%)

~ Self-employed insured (32.9%) .·

# Medical Aid : 3.4% (low income)

13.11<;;.

- --~ - · .. -· . - --0 Health Insurance Fmanctal Status

'•"""'' -<-- "'1{.

Revenue 168.231 185.72 203,325 223.876 252 ,697 289 ,079 311,817 335,G05 2

Expense ) 57.~ 37 170.Q4

191,537 224 ,623 255,544 275,412 311 ,349 348,599 3

Dilterenee 10 ,794 15,679 11.788 Do 747 t::. 2,847 13,667 6 32 6

(Current) 12.994

DiUerence 6 14 ,92 U.......U..~)

2 757 12,545 11,798 8 ,951 22,618 22,586 9,592

Number of I Numbcrof physicians nursinn

personnel

6EC0aver.~ge 3 .9 3.1 9.6

HLu~~• Cl>.!i"PY 8.2 5.4 31.9

l..owet.l cou.ntr:y 1.0 1.5 2,0

Source: OECD Hulth Databa~ (1:oog).

f Appeal system The NHIC, health care ln6tltutions, .end patients have a right to make an ~peal to the HIRA to reverse a decision by the Nation.-! Health lneuranc:e Ac:t

Annex4

'i;l .. • All the medical facilities are by law required to

provide health services for the insured.

9 ' Weak referral channel (Free choice ?f provider)

·9, • More than 90% of physicians working in the private

sector

-fl More than 96% of all hospitals and clinics, and 92%

of beds privately owned

---~ 0 Payment system

. __ ,

,~; FFS system to both inpatient and outpatient care

.. Annual fee schedule through negotiation between

NHIC and each provider group

• When negotiation fails, the Minister of Health and

Welfare determines the fee levels through a

committee meeting of three parties including civic

groups, providers and the government

Pb_annaceuticaJs

40,,\_ur (lriiatmenJ co~+

CO!l1iuiiationlu)

30 .orlre~tment oost

In-patient 20% ortolal cost; out-patients 30%

Annex 4

GQIO OO • Conb1bil'lto~:rs;

.. eena1\t5 50,000

44,000

30,000

2.0,000

10,000

D

"""' lowest 1st 2nd

• R.ltio • IM!:nl!flb:/contrlbuthmt

0.98

3rd 4th Highest 5th

9.1%

~--- . . . - __.... 0 p p g

-.fl.' ... - .(; •••

-~f·~~;~-~~YJ.f-=-:.:-=.~:'.~::·.,_:-=.=::.:-=.:::.:·=-==: :-:::~.:-.. =-:.?W-.Y.!-:.;-=: . .-.~-;;:;.:..:_=;=:=-=-=.=.:·;.=.=.:~~~~:~.:~f~ t; 1.. A.1111Ual l'l,lllr.ag• rw.l (,lt OW(h ih per bl~ll~ h .. lth •lis-n-di:lr.llll, Hili' II) Z007'

,~ Reducing costs on pharmaceuticals

'9 . Encouraging healthy ageing

,~, Improving management efficiency

• Facilitating competition under a single insurer

'" ' Reducing the burden of high out-of-pocket by

increasing public share of health expenditure

Annex4

Annex4

Dissemination workshop of study results The financial burden of health payments

23-24 March 2011

Manila, Philippines

REGIONAL POLICY BRIEF

REDUCING THE IMPACT OF HIGH OOP PAYMENTS FOR HEALTH

IN THE ASIA PACIFIC (PRELIMINARY, FOR DISCUSSION)

Why a high reliance on OOP payments matters

Short summary of main points, based on WHO World Health Report 2010 and Regional Strategy - Whilst sufficient resources for health is a key

prerequisite, payment should not be over-reliant on direct (OOP) payments ...

- OOP payments inhibit access, esp. for the poor. - OOP payments and risk of financial catastrophe I

impoverishment - Linkages to country studies - Targets from WHR 2010 (15-20%) and Regional

Strategy (30-40%)

Introduction Aim

To complement country policy briefs by providing: 1. regional picture of reliance on high OOP payments 2. policy recommendations (building on WHR201 0)

Length (5 pages max)+ Timeframe (August) Structure

Why a high reliance on OOP payments matters The situation in Asia & the Pacific (countries grouped based on reliance on OOP) What can be done- policy recommendations (by country groupings, with links to country policy briefs)

The Situation in Asia & the Pacific

Reliance on OOP payments much higher in the Asia Pacific than other parts of the world (often with corresponding low government spending on health) More people face financial catastrophe or impoverishment because of health payments than in other regions. There are, though, important differences across countries within the region. High OOP payments are of particular concern when combined with low government spending on health.

Eastern Jvi?ditenanean

Afiica [J in"CDverls fled

I financial catastrophe Europe

SOLtfrEastAI ia

0 30 60

N.lllber of people (nillion)

Impoverishm ent and financial catastrophe due to health care costs, by WHO region fC!"'JCe:.Xu.!! al, 2001, "'ProMC'bo hflM~o."ds from Qlll~lrcphlc!N.-1\h ~tp6ndinljl,· H~.alltl A.tfllirt., 2S:-4'!nM&l.

OOP as %of THE- 2008" j_GGHE pc, US$- 2007'"

' · tilt h 10!1..,-o<lon 00~ OOf':>o!O" "'loW'gOVl a"'"''!liiii on h<iillllt' (Oilf!E'p¢'< IJSS44_l: fflllnbodia 65% $10 Lao PDR 63% $5 Philippines 56% $22

' I "'o -~'

~?0

China 49% S49 2a. HiQtl n~lia,nooon OOJ:Iln1t.'.rr.t$Onablu ' l0vol ot govt ,cpending=oh ltoalth GGHE ,.,0 > . §ll!gapore 61% $375 Malaysi? 41% $136 1(~. "" .tu~

~6. LQo,~i,.lbn<e.on OOP OOP~% bur low goVI . ,.ndlnn on hoohh OGHEJ>c _c $44/ PAl9~gotia 18% 552 Vanuatu 15% $61 Papua New Guinea 8% $25 Snlnmnn l<lonrl< d% ~-'n 3. Some rollllnce on OOP(OOP 20·40% + ' re.asona.hle' love.l cfGGHE GGHE De> $80 Tonga; F'jl, Nauru

4. Low reliance on OOfi {OOP < '2.0%} +'reasonable' level of GGHE (GGl1E s:te > SBD) Brunei Darussalam; Australia; Japan; New Zealand; Samoa; Palau; Cook Islands; Federated States of Micronesia; Marshall Islands; Kiribati: Tuvalu

Progressive realization

Towards universal coverage

/!. Jtt-41.1 (11 CO\\lltiriR;II"11Dd fllllll ~

i-&t111.ruito

~-~~-~·~~!~~.)> fim~!gJJ~,

Policy recommendations for reducing OOP: increasing government funding

Strive to make health I universal coverage a key political issue

Assess likely fiscal space for health - Govt priority to health+ Revenue base(+ External

aid)

Budget negotiations: make a stronger case - Results-oriented, accountability, transparency,

coherence (NHPSP, MTEF, ... ) - Links to socioeconomic development

Allllex 4

What can be done

General policy directions by country groupings (on basis of country's reliance on OOP and government

spending on health)

Policy recommendations in relation to each of 3 fundamental health financing challenges detailed in World Health Report 2010 & with linkages to country­specific policy briefs

General policy directions by country grouping Increase Reduce Increased focus

government financial on efficiency funding barriers gains

earnllPif\a, Liiio"Po~ Pliine_.l>jltes. Vte\.Nilm ~Tml Singapore. Malaysia, Korea

MDIJ90lia. ~NG, VanuatU, S¢_[fl!11QOJSja}lcfs Tonga, Fiji, Nauru

All otherWPR: high-income & PICTs (that are not listed above)

Policy recommendations for reducing OOP: reducing financial barriers

Focus on population groups with least protection - E.g. subsidised insurance premiums; no direct

payments; vouchers I CCTs

Agree road map to universal coverage: move from fragmented to consolidated social health protection - Multiple social health protection schemes: timeline for

merger or risk equalization measures - Compulsory contribution - Subsidies of informal sector as well as the poor

Annex4

Policy recommendations for reducing OOP: increased focus on efficiency gains

Leading sources of Inefficiency (WHR 201 0) - Medicines (generics use, procurement prices +

substandard/counterfeits+ Inappropriate use) - Products and services (overuse) - Health workers (staff mix, low motivation) - Health services (hospital admissions, LOS + low occupancy rates +

medical error, low quality) - Health system leakages (waste, corruption, fraud) - Health interventions (inefficient mix /level)

~ Addressing perverse incentives + more active purchasing (from both private and public sectors)

Timeline

o First draft circulated -June (incorporating findings from country policy briefs)

• Comments

o Final draft- July I August

Annex4

Dissemination workshop of study results: the financial burden of health payments

23-24 March 2011 Manila, Philippines

NiEX_T STEPS

DISCUSSION POINTS

• Analytical work on monitoring the financial burden of payments

• Other health financing analytical work (including available approaches I tools)

• Support to health financing strategies, regulations, etc

• Partnerships

(.\World .He~lth ~·J Orgamzat1on ~

Western Pacific Region www. wpro. who. i nt