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International Multi-stakeholder Consultation on National AIDS Programmes Sustainability Nairobi, April 19 -20, 2012 A

International Multi-stakeholder Consultation on National AIDS Programmes Sustainability Nairobi, April 19 -20, 2012 Anton Pruijssers. Content. Introduction: a perspective on Health in Africa Pivotal question 3 cases Conclusions. 1.1 Health in Africa Africa spends little on health.

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International Multi-stakeholder Consultation on National AIDS Programmes Sustainability Nairobi, April 19 -20, 2012 A

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  1. International Multi-stakeholder Consultation on National AIDS Programmes Sustainability Nairobi, April 19 -20, 2012 Anton Pruijssers

  2. Content • Introduction: a perspective on Health in Africa • Pivotal question • 3 cases • Conclusions

  3. 1.1 Health in AfricaAfrica spends little on health • Africa is home to more than 10% of the worlds population, • almost half of the burden of communicable diseases, but • less than 1% of health expenditure is spent in Africa Population (millions) Burden of communicable diseases (million DALYS) Total health expenditure(million USD) Africa Rest of the world Source, WHO 2008

  4. 1.2 Health in AfricaFirst law of health economics • the tight relationship between income and health expenditure leaves littleroom for maneuver Source: WDI data, 2006

  5. 1.3 Health in AfricaThe private health sector is a major provider for the poor • > 40% in lowest income quintile receive health care from private for-profit providers • Investments in the private sector are low Percentage of people seeking health services in private health facilities Data based on usage, not expenditure (most recent survey year available between 1995-2006) Source: World Bank, 2006, Africa Development Indicators

  6. 1.4 Health in AfricaOut-of-pocket payments are high • Private out-of-pocket expenses contribute ~50% to total health expenditure in Africa Out-of-pocket health expenditure as a percentage of total health expenditure Source: WHO 2008

  7. 1.5 Health in AfricaHealth insurance is rare • risk pooling in Africa is scarce, solidarity is limited Socialsecurity and private prepaid health care spending Only 4% of total health expenditure in Africa is financed through health insurance Source: WHO 2008

  8. 1.6 Health in Africa; Inefficient institutions, implications for behavior • Individuals • Prefer lower, short-term gains over higher, future gains • high discount rates -> poverty trap • Social groups • trust is limited to the group • no institutions to arrange benefit entitlement • Companies • high interest rates 40-200% -> high discount rates -> negative Net Present Value -> little investment

  9. 1.7 Summary on health in Africa: a vicious cycle • African health systems are stuck in a vicious circle of low demand and low supply of health care. Trust in the system is low. • Unknown and unbearable risk is a crucial factor hampering investments Financing Low Demand Supply Risk • High out-of-pocket expenses • Low access • Low ownership • Low solidarity • Low quality health care • Low efficiency • High risk • Scarcity of data Low Low Delivery Low Patient • Catastrophic spending • Low utilization

  10. 2. Pivotal question How and where to break this vicious cycle and transform it into A virtuous cycle of access for all to healthcare of good quality in a sustainable way?

  11. 3. Three cases Case 3. Health Insurance Case 2. Credit for Medical Providers Demand Financing Supply High Case 1. Medical Quality Assessment & Improvement Trust High High Delivery High Patient

  12. Case 1: Quality standards and quality improvement The SafeCare Initiative was started in 2011, a collaboration of: => • Comprises of innovative and realistic standards for healthcare providers in resource restricted settings. • Standards have been approved by the international accrediting body of accreditorsISQua • Linked to a step-wise improvement process • These incentives will eventually improve the reputationof these healthcare facilities • Clients are expected to have increased trust in services provided

  13. Case 1: SafeCare - Highlights • 200+ facilitiesassessedusing SafeCare methodology through PharmAccess programs in Kenya, Tanzania, Ghana, Namibia and Nigeria • 35 local surveyors and facilitatorstrained • APHIA plus: USAID program forKenya, SafeCare as externalvalidationforsocialfranchises (e.g. PSI/Marie StopesInt’l) • NHIF Kenya: proposal to developstepwisecertification of healthcarefacilities in the newoutpatientscheme • MOSH Nigeria: development of concept noteforTechnicalAssistanceonstepwisecertification of 1,000 PHC clinics • AHME (Gates/DFID) fundingawaitingfinalapproval (4.3 million USD forKenya, Ghana and Nigeria)

  14. Case 2: Credits to medical providers Medical Credit Fund provides affordable loans to private medical providers through local banks • Local partners provide Technical Assistance on: • Quality assessment and improvement (SafeCare) • Business training • Preparing financial statements and business plan • Support with filing of loan application • Medical providers become bankable • Risk sharing arrangement with bank • Winner of G-20 Challenge

  15. Case 2: Credits to medical providersLeverage of public money, and revolving Value of Public and Private Funding and Loans in Medical Credit Fund (USD) Participants: OPIC, Dutch Government, Soros, USAID, Calvert Foundation, IFC-G20 65 m USD Revolving 30 m USD Leverage 13 m USD

  16. Case 2: MCF – Performance to date

  17. Case 3: Health Insurance Fund (HIF) • Community-based voluntary health insurance schemes in Nigeria, Tanzania, Kenya, Mozambique and Namibia • Implemented by local private health insurance companies and TPAs e.g. Hygeia, AAR, Medilink and MicroEnsure • Public funds from: • Dutch Ministry of Foreign Affairs • The World Bank • USAID • Kwara State Government

  18. Case 3: Health Insurance Fund - Enrolment

  19. Case 3: Health Insurance Fund Nigeria Donor commitment to health insurance Nigeria 30 m Euro for 5 years Spent today 10 m Euro Investments by Private Parties 30 m Euro Demand Supply Financing High • 8 m Euro spent on 95,000 farmers and market staff • Nigerian HMO spent 2 m on admin including profit Trust High High Delivery High Patient Prepayment by users 0.8 m Euro Kwara state government 2.4 m Euro

  20. Case 3: Health Insurance Fund NigeriaResults • Public commitments led to private investments • Total money in the system has increased >3 times • Mobilizing (voluntary) pre-payments from individuals => getting more money in the system long term => leveraging public and donor funding => pre-payments may be increased step-by-step, but only in parallel to growth in the health system’s capacity, both in volume and quality • Familiarize individuals with concept of (health) insurance

  21. Case 3: Health Insurance FundInteraction with vertical programs • Comprehensive package covering basic primary health care, maternal and neonatal care as well as inpatient care • Includes basic screening functions for e.g. HIV/AIDS, STD, TB, malaria, diabetes, hypertension • For most diagnoses, treatments including drugs are covered • Refers positive HIV/AIDS cases to the providers with vertical funding, increasing the number of found cases => increased impact on a community level • Interactions and synergies with vertical programs can be optimized further

  22. Summary -1- • Health systems in Africa are stuck in a vicious circle of low demand, low quality of care and little investment • Donor and government funds should be applied to reduce the risk in the sector, stimulate risk pooling mechanisms and attract private investments • Implementing quality standards and quality improvement processes will increase trust in the system • Transformation from a vicious cycle to a virtuous cycle takes time and requires well-balanced mobilization of public, donor and private funds

  23. Summary -2- • Achievement of a sustainable increase of the total amount of money in the system can be realized by introducing voluntary prepayments in insurance • Interactions and synergies with vertical programs can be optimized further • With more money in the system and increasing trust, investments will be stimulated in turn, building the virtuous cycle

  24. International Multi-stakeholder Consultationon National AIDS Programmes Thank you for your attention QUESTIONS?? Anton Pruijssers Director Operations Health Insurance PharmAccess Foundation +31 615 118 118 a.pruijssers@pharmaccess.org

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