Transcript 1 International Health Financing Policies

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International Health Financing
Policies
J.-P. Unger
Public sector health care unit
Institute of Tropical Medicine, Antwerp, Belgium
A presentation to Medicus Mundi Spain
June, 2013
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Plan
1. International health financing policies in LIC
2.International health financing policies in MIC
3.Alternative options
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1. International policies on
health care delivery and financing in
LIC
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Alleged objectives of
international health policy (MDGs)
• Reduce mortality by AIDS, TB, malaria
• Reduce maternal and child mortality
• Avoid communicable diseases spilling over in HIC
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International health policy
forgotten objectives
• Improve equity in access to care
• Reduce adult mortality
• Reduce morbidity and suffering in children and adults
• Control biological and social determinants of illness
• Limit spread of resistance to drugs
• Control health expenditure
International
doctrine
Disease control
programs
Health care
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MOH
private
X
(x)
X
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Failure to reach (the quite limited)
MDGs and even to progress in LIC
• ± 50% of PLWHA needing treatment were receiving the
medicines in 2009 (36% with new guidelines), far from the
100% aimed at in 2010
• TB prevalence in Africa: 1990-2007: +47%
• Health care expenditure remains 1st cause of falling into
poverty
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Avoidable mortality and suffering
• 11 million avoidable deaths attributable to communicable
diseases yearly
• ± 10 million avoidable deaths due to chronic diseases
yearly
• Generalised torture – avoidable suffering in LMIC by lack of
access to care and drugs (a human right?)
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Inefficiency of international aid
• More than 120 disease control programs expanded
between
• Washington, Brussels and Geneva
• LMIC capitals, towns and villages of LIC (with VHW)
• The biggest ever created bureaucracy
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Total annual resources needed for AIDS
under disease-specific organisation pattern
17th March, 2011
European Parliament
Funding gap
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Why this failure to control diseases?
A negative feed back loop
1. for success, disease control programmes need patients
consulting for various symptoms. They represent a pool of
users that disease control programmes need for early case
detection and sufficient coverage.
Can malaria be controlled where basic health services are not used? Tropical Medicine and International
Health, 2006; 11(3):314-322
2. neoliberal policies allocate patients to private sector and
disease control to public
Letter. Public health implications of world trade negotiations. Lancet, 2004, 363: 83
3. while disease control programs limit access to care in
public services e.g. polarizing them according to their
interests
2003. A code of best practice for disease control programmes to avoid damaging health care services in
developing countries Int J Health Planning and Management 2003, 18: S27-S39
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Why has access to health care been left out
of international health policies in LICs?
• Not because costs: costs of a few disease control
programmes in DCs = costs of family medicine
encompassing the same programmes
Selective Primary Health Care: a critical review of Methods and Results. Soc. Sci. Med. 1986; 22,
1001-1013
• Because no subsided competition with the private sector
is tolerated where there is a demand.
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The international policy undermine
LIC health systems
Segmentation and fragmentation of systems
• No more first line individual health care delivery
• Proliferation of disease specific programs (52 in
Congo)
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The international policy undermined health
systems in LIC
• Limited responsiveness of health systems to respond to
users demand and to host disease control programs
• Community participation and support vanished
• Poor status of public services professionals
• Internal brain drain (LIC++)
2009. International health policy and stagnating maternal mortality: is there a causal link? Reprod
Health Matters, 17,33: 91-104
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Overall impact on health care
• 1990: almost 50% fail to provide adequate access to care
for their citizens in LIC and MIC
UNDP. Department of Economic and Social Affairs, Population Division, United Nations, New York.
ST/ESA/SER.R/151, 2000
• access to care particularly difficult in China, former Soviet
Union, Africa
• no recent global data (to our best knowledge)
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2. MIC health policies
Comparing Colombia, Chile and Costa Rica
• Colombia, in vivo test of health care privatisation in
developing countries. Int J Health Services
• Costa Rica: Achievements of a heterodox health policy.
American Journal of Public Health
• Chile, a neoliberal success story? PLoS
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Old inter-country comparisons
Costa Rica
Chile
Colombia
IMR
1970
62
78
69
IMR
2001
9
10
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Reduction
IMR
1970-2001
:7
:8
:4
MMR
2001
29
23
80
Notice:
16% of Chilean population consumes 50% of health expenditure
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Health and Equity Indicators
Costa Rica vs United States (2002)
Costa Rica
USA
GDP per capita (PPP USD)
health expenditure per capita
9,460
34,320
562
4,887
infant mortality rate
9
7
life expectancy at birth
78
77
Gini index
46.5
40.8
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MIC/US health policies: a universal model
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The new international health policy objective:
universal coverage
• Promoted by France, Germany, USA…
• And WHO (WHR 2010)
• Alleged justifications:
• out-of-pocket expenditure hampers access
• chronic diseases become a burden (demographic transition)
• Objective: open LMIC middle class market of health
insurance to high income countries banks
• Example: main Chilean Isapres belong to 3 EU / US banks
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Misleading universal insurance coverage
• Colombia 1997-2003:
• insurance coverage rate from 54% up to 62% but
• outpatient consultation rate 23.8% down to 9.5%
• Peru 2007 – 2008:
• social Insurance coverage from 42,7 up to 63,5% in extremely poor population
and from 26.6 to 44.7 in the other but
• those who didn’t consult increased from 50.5 to 56%
• Burkina Faso 2008:
• Made C-sections free at the point of delivery but
• c-section rate up by 20% only
• Ghana 2007 -2009:
• insurance coverage increasing from 0% to 60% but
• user fees increased from 9 to 11% of total health expenditure
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(Insurance!) universal coverage,
a fashionable strategy unlikely to work
All these examples point to the existence of significant nonfinancial barriers to
• access to individual health care
• limited effectiveness of health insurance in LMIC
• the lure of focusing public financing on the poor (≠ Western
Europe)
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Why did social health insurances fail
in LMIC?
Because
•paradoxically, governments focused public financing /
social insurance on the poor!
•…which led middle classes to deny any contribution to
health care public financing as they couldn’t take
advantage of it
•To the contrary, in Western Europe, social organizations
forced a single universal pooled prepayment system
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Why did social health insurances fail
in LMIC?
Because of limited effectiveness of regulation and control in
LMICs
•Hesvic project: evaluation of regulation in Chinese, Vietnamese
and Indian maternal health sectors
8 / 9 = failures; 1 / 9 = central planning
•Failure of PFP in Costa Rica
•Failure of Chilean and Colombian health policies are partly linked
to failures of their ‘superintendencia’ (contraloria)
•Mechanisms are related to LIC / MIC States features
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The international policy undermine
LIC health systems
Segmentation and fragmentation of systems
• Management property split = commercial privatisation of public
hospitals (ex. China)
• Municipalization of health services (from Philippines to Brazil)
• Bolivia: 4 authorities (national and local governments, region,
and international cooperation) for 1 health centre
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The hidden motives of this policy
• 16% of GDP (USA) – 8% of GDP (Spain)= 8% of the world
GDP
• The biggest worldwide market to earn?
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Past and future GDP at market prices
(trillions of euro)
EU
2007 2008 2009 2010 2011
2012 2013 2019
12.4
12.9
12.45 11.7
12.25 12.6
13.4
14.4
??
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Non health economic actors will lose market shares if
Europe health system moves towards a US like one
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Alternative options in health care
delivery policies
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A new MDG: universal access to
versatile, individual health care
• family and community medicine
• general hospital care
• disease control
• integrated control of social determinants
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Instead of insurance coverage indicators,
promote indicators of access to decent care
•
•
•
•
Examples
Hospital admission rates
First line utilisation rates
TB and AIDS case fatality rates
Referral completion rate
None of them are requested by WHO / released by
countries!
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Such care should meet simple quality
criteria
Care should be
•continuous (to avoid resistance to antiretroviral and TB statics)
•integrated (to enable the patient moving to the appropriate
program and reduce bureaucratic costs)
•bio-psychosocial (to be effective /acceptable)
•effective e.g. tuberculosis case fatality rate
•Efficient (to be compatible with solidarity)
•Not-for profit (to be compatible with the Hippocratic Oath)
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Promote a health sector with a social
mission
Mission
(Status)
MOH
Social
(Government)
Commercial
(Private)
Care + Disease
Care
control
private
Care + Disease
control
Care
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Strategic priorities for health systems
strengthening
1. Integrate and strengthen the sector of publicly oriented
(socially motivated) health care delivery
2. Integrate administration of disease control programs into
general health care management
3. Strengthen bio-psychosocial care in first line
4. Strengthen general hospitals
5. Coordinate first line services + Hospital in a local health
system to improve care coordination and knowledge
transfer
6. Steer field experiments
7. Promote bottom up planning towards national health policy
Addressing fragmentation with integrated networks
H
Interinstitutional
management of local
health systems
Professional management and
deconcentrated budgets are needed
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4. Alternative options in health financing
Let’s not target the poor with public financing if
we want national solidarity and equity
Let’s export the principles of the West-European
health financing system
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An alternative financing pattern for
segmented health systems
Notice: supply side financing doesn’t permit to only finance
MOH services
MoH
Taxes
(or Bismarkian)
Demandside
financing
National
health fund
Commercial
sector
Not for profit MoH services
private org.
Individuals
Social sector
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Thank you
[email protected]
www.jeanpierreunger.com