Transcript Implementing health sector reforms and addressing public financing

Implementing health sector
reforms and addressing public
financing constraints: can they go
hand in hand?
Irina Smirnov, Economist, The
World Bank
Constitutional provisions in Health
Insurance and Care system
State BiH
Republika Srpska
Canton A
Federation BiH
Canton B
Brčko District
Canton C
Republika Srpska Health System
Central Government
Ministry of Health
Public Health Insurance Fund
Institute for Public Health
Primary health care assigned to the local government level
Resource base: contributions, other payments by contributors and other sources
Federation Health System
Federation BiH
Canton A
Municipality B1
Canton B
Municipality B2
Canton C
Municipality B3
Canton A
Min. of Health
PHF
HIF
Wide variations accross cantons in access to health services
Health Spending in BiH
Health care financing and delivery systems are fragile
and not sustainable
Ongoing reforms are both broader and in a more advanced state than in
other social sectors, yet need to be deepened to ensure sustainability
and improve the efficiency, equity and quality
Per capita expenditures in Health Sector (in KM),
1999
Revenues and expenditures of BiH Health Sector,
1999
8,5
9,0
8,0
8,0
7,7
8,0
6,8
7,0
250,0
6,7
6,0
200,0
5,0
226,0
175,0
150,0
KM
4,0
3,0
98,0
100,0
2,0
1,0
50,0
0,0
BiH
FBiH
RS
0,0
Revenues as % of GDP
Expenditures as % of GDP
BiH
Besides that , 4.7 % GDP in private
payments
Per capita expenditures
(in KM)
FBiH
RS
Health Spending in BiH (2)
Financing of health care scores poorly on equity and
efficiency, despite the good intentions of the
system’s designers
Fragmentation of the system – no economies of scale
and no risk-sharing
Information systems are under-developed and there is
no information exchange
Barriers hinder access to health care
underfunding results in rationing
arrears in insurance contribution payments makes access
uncertain
Cross-border care (Entities, cantons) coordination, portability
of insurance
Health Spending in BiH (3)
Most available health indicators in BiH are
acceptable for low-income countries; but, BiH’s
health sector, like others in Eastern Europe,
under-emphasizes health promotion and disease
prevention
Fragmentation and weak management of the
system – lack of coordination and inefficient use
of specialized skills
Limited resources and role of PHIs in FBiH in
planning, analysis and informed decision-making
Health Spending in BiH (4)
Public dissatisfaction with health care in BiH
Wrong mix of primary, secondary, and tertiary
levels of care and facilities
Shortages of materials and equipment and
uneven knowledge of medical protocols
A physician-dominated health care system that
does not utilize the potential for nurses and
other health professionals
Health Reforms are needed...
The challenge: reintegrating the system to better
exploit economies of scale in the delivery,
financing, and administration of health care
Improve financial sustainability/discipline,
flexibility and equity
enforcing revenue collection and broader coverage
assigning function with positive externalities to the FBiH
government (primary health care)
implementing hard budget constraints
establishing global budgets for health care facilities
higher level of co-payments, with exemptions for the needy
Pursuing better coordination through the State government
Health Reforms are needed...
The challenge also includes...
Introducing clear rules for the administration of
private payments:
prohibiting receipt of private payments by publicly
employed doctors for services provided as part of
their normal duties,
allowing private payments to non-publiclyemployed doctors if they are transparent and do not
conflict with related public policies,
levying charges set at cost-recovery levels for the
use of publicly owned facilities by doctors who are
practicing privately
Health Reforms are needed...
And last but not the least...
Strengthening Effectiveness of Delivery
Systems
Rationalizing the network of health facilities
Coordinating health care and rationalizing facility
capabilities across Entity borders, and, in the Federation,
across cantonal borders to avoid duplication of services
Assessing the overall effectiveness and efficiency with
which pharmaceuticals are procured and used in BiH
Strengthen procurement processes for equipment and
materials
And the main question is still unanswered...
Public spending on health in BiH will NOT grow
over medium term
However, reforms must continue,
efficiency, equity and quality need
to improve