Health Reform and Financing Strategies for Improved Population Health

1. Health Reform, Health Financing, and Population Health Dominic S. Haazen, Sr. Health Specialist, The World Bank Riga, Latvia

2. Presentation Outline • Program of Action elements relevant to this discussion • Key health reform interventions in the countries in transition • Developments in health financing and payment systems • Recent developments in HIV/AIDS • Implications for population health

3. Program of Action – ICPD 1994 • universal access - primary health care • universal access – comprehensive reproductive health services • including family planning • reductions in infant, child and maternal morbidity and mortality • increased life expectancy

4. Accomplishments – ICPD+5 1999 • population concerns integrated into development strategies in many countries • mortality in most countries continued to fall • broad-based definition of reproductive health increasingly accepted • steps being taken to provide comprehensive services in many countries • increasing emphasis on quality of care • rising use of family planning methods • greater accessibility to family planning

5. Unfinished Agenda – ICPD+5 1999 • Still unacceptably high mortality/morbidity • HIV/AIDS • Infectious diseases, such as tuberculosis • Maternal mortality/morbidity • Adult NCD mortality for countries with economies in transition , especially among men • Adolescents particularly vulnerable to reproductive and sexual risks. • Lack of access by many to reproductive health information and services

6. Constraints/Needs – ICPD+5 1999 • financial, institutional, HR constraints • greater political commitment needed • national capacity must be developed, but increased international assistance is needed • more domestic resources must be allocated • effective priority-setting within each national context is an critical factor • integrated approach: policy design, planning, service delivery, research and monitoring

7. Action Items – ICPD+5 1999 • ensure social safety nets are implemented • strengthen specific health programs: • infant/child health programs that improve prenatal care and nutrition, • maternal health services, • quality family-planning services • efforts to prevent transmission of HIV/AIDS and other sexually transmitted diseases;

8. Action Items – ICPD+5 1999 • strengthen health-care systems to respond to priority demands • ensure resources are focused on the health needs of people in poverty • develop special policies and health promotion programs to address rising or stagnating mortality levels • strengthen national information systems to produce reliable statistics in a timely manner.

9. Key Health Reforms – ECA Region • Introduction of primary health care • Decentralization of health facilities • Health insurance (various models) • Provider payment reforms • Rationalization of health services • Hospitals, EMS, PHC, specialists • Introduction of health promotion and prevention approaches, strategies • Adoption of DOTS

10. WB Supported Interventions – 1991-2001

11. Health Financing Dimensions • Revenue raising – amount/method • Pooling of funds • Resource allocation • Coverage/benefit package • Out of pocket payments • Purchasing methods

12. Health System Financing & Population Links

13. Revenue Raising Methods • payroll tax emerged as a standard source of health care financing • 14 countries have payroll taxes: 9 as main financing mechanism, 5 as complementary • contribution rates range from 2% in Kyrgzstan to 18% in Croatia • 7 countries rely primarily on taxation • Out-of-pocket costs range from less than 20% in Slovenia and Croatia to over 80% in Georgia and Azerbaijan

14. Out of Pocket Payments in ECA

15. Out of Pocket Payments - Impact • OOP payments affect treatment choice • riskier interventions such as surgery require larger payments • Services that may be seen as discretionary (pre- and post-natal care), may be avoided • Quality of care and waiting times may depend on ability to pay • Undermines universality of publicly financed health programs

16. Revenue Raising Capacity …

17. … and Impact on Health Spending

18. Public Health Spending vs. GDP

19. Coverage – “Basket of Services” • Many/most countries have attempted to define, but with limited success • 14 studies funded through WB alone • e.g., Armenia - universal coverage only for primary/emergency services; some secondary services available only for the poor • Even when defined, non-poor often benefit disproportionately • Definition of “emergency” in Armenia • Urban-rural disparities in access

20. Payment Methods – Physician Services

21. Payment Methods – Physician Services

22. Payment Methods – Inpatient Care

23. Payment Methods and Incentives

24. Provider Payment Methods - Impact • Any one method by itself does not satisfy all objectives • Additional incentives are needed to address those inherent in selected approach • More sophisticated methods often require information systems that may not (yet) be available in transition countries

28. HIV/AIDS Regional Support Strategy • Raising political and social commitment • Generating/using essential information • Estimating the economic and social impact • Improving surveillance • Maximizing value for money • Estimating resource requirements • Prevention of TB and HIV/AIDS • Harm reduction, focus: CSW, IDU, prisons • Sustainable, high quality care • Facilitating large-scale implementation

29. Implications for Population Health • Unfinished rationalization agenda: • Misallocation of resources • Service quality (incl. reproductive health) • Under-funding of PHC and prevention • Limited public funding in many countries • Reproductive health must compete • Challenge to ensure access for poor/rural • Provider payment systems incentives • Must encourage RH related activities

30. Implications for Population Health • Primary health care “immature” • Obs./Gyn. specialists still do most RH • Public confidence in PHC abilities • Information systems tell us little about what is going on (“known unknowns”?) • Amount of ante-natal/post-natal care • Other reproductive health activities • Hospitalization (ALOS, C-section, comp.) • Disease surveillance

31. Thank you!! Dominic S. Haazen, Sr. Health Specialist, The World Bank Riga, Latvia dhaazen@worldbank.org