Universal Coverage and Equity in Integrated Health Governance Systems

1. Universal Coverage And Equity In Integrated Health Governance SystemsDirector General HealthPeoples Health AssemblySouth Africa 09 July 2012

2. Outline of the Presentation • Background • Pillars • Opportunities • Renewed interest in PHC • Crises • Various perspectives • A response-Comprehensive PHC • Lessons from other countries • SA Response, 10 point plan, NSDA

3. Universal Coverage This principle is based on the understanding that the progressive development of a health system, including its financing mechanisms, should be founded on the principles of access to quality needed health services and protection from financial hardships It implies that everyone must be given an equitable and timely opportunity to access needed health services, which must include n appropriate mix of promotion, prevention, curative and rehabilitative care.

4. Crises and social spending • Financial crisis and rising unemployment, cannot be basis for cutting allocations for social services • Most countries have seen a decline in public health expenditure and increase in inequities, deterioration in health • Can be minimised, or impact can be reduced through a comprehensive primary health care and universal coverage

5. Various perspectives on the importance of health • Commission on Macroeconomics and Health (2001 )-health has been considered a central goal of development and an instrument to enhance other welfare outcomes • AmartyaSen (1999) presented a philosophical perspective , that health is an essential element of the human capabilities needed for development • Bloom and Canning (2000), an economic perspective, consider population health as key in contributing towards economic growth at a national level • Liu et al (2003) on poverty , poor health is linked to poverty and household distress • Access to healthcare is a human right enshrined in the constitution

6. Renewed interest on PHC • Thirty four years ago- Alma Ata declaration • Four years ago WHO World Health Report 2008 devoted to PHC, “ Primary Health care, Now More Than Ever” • The Lancet 2008series- “30 years after Alma-Ata: has primary health care worked in countries” • Commission on Social Determinants on Health • The Lancet (Julio Frenk, 2009) “Reinventing Primary Health Care: the need for systems integration” • Subsequent declarations, e.g. RIO Declaration on the Social Determinants of Heath, and RIO 20+

7. Comprehensive primary health care • Elements of a comprehensive approach include equity, high coverage, governance, effective inter-sectoral action, the responsiveness of the non-health sector and community participation • Comprehensive primary health care must be an integration of preventative, promotive, therapeutic and rehabilitative

8. International Experiences Many governments have made attempts to reform health Some have created new insurance schemes, others have changed how primary healthcare is delivered, restructured hospital governance, decentralised service delivery Many of the reforms have yielded mixed results, a combination of successes and failures, improvements in some areas and slow progress in others

9. Success stories • Common features among countries with experiences in rolling out PHC are, in an integrated manner, with community participation, use of community health workers, focus on social determinants of health (Thailand, Rwanda, Brazil)

10. Lessons for South Africa Countries differ in their level of development, social conditions, value systems, disease profiles, effectiveness of their governance structures and institutions Every country must reform its health system with the involvement and participation of its citizens, mobilisation of its communities, the beneficiaries

11. Pillars for an integrated approach Health Financing Health Service Provision Governance and Institutional arrangements Regulatory environment

12. Health Financing • Countries do not finance healthcare through a single mechanism • There are a combination approaches: • Public • Private • Combination of both • Multiple health plans

13. Health Service Provision Predominantly publicly provided services- Scandinavian countries Combination of government care and private health providers (UK) Predominantly private providers (Swiss)

14. South Africa • Nationally agreed prioritised and phased primary health care, with special attention to strengthening district health system

15. Private • Individual private insurance, that may be: • community based health insurance, or • medical savings account, or • private health insurance e.g. medical schemes

16. Public • Payment through taxes or compulsory health insurance: • Social health insurance,(contributions from employer and employee, it is limited to the formal employment sector), • National health insurance, (prepayment scheme that is mandatory and is a compulsory health insurance) • Tax-based finance system (government revenue the main source) (Source: Global Health Watch 3, 2011)

17. Social Health Insurance Limited to the formal employed sector Excludes a significant proportion of the informal employed and self employed sector It has a small pool and hence universal coverage may not be achievable It is socially acceptable to the employed sector May contribute to higher labour costs

18. Tax-based finance system It is a form of prepayment and government is the main source of funding It does not link payment to risk and detaches payment from the experience of ill-health It has better potential in achieving universal coverage and financial protection It may promote social cohesion across different groups

19. Tax-based finance system It requires both fiscal and social contract between the state and society It must be the means by which the state can be made accountable to society

20. Private Health Insurance Self financing scheme for the affluent It is highly selective and universal coverage may not be achievable as it only covers a small proportion of the population Requires robust regulatory systems Countries with predominantly private health insurance schemes are Netherlands, Switzerland and USA In the US, 50 million people are uninsured despite the fact that 2,3 trillion is spent on healthcare ( G. Halvvorson, 2009)

21. Community Based Health Insurance A scheme that is operated by organisations other than government of private for profit sector It may cover part of or all of the healthcare costs It is voluntary and is low cost, with administration managed by the communities themselves It largely provides cover for the socially excluded or populations in the informal sector the schemes have a potential to reduce financial burdens on individuals and reduce out of pocket payments

22. Community Based Health Insurance • Those without income may not benefit, and thus universal coverage may not be possible without government subsidy • The biggest challenge is long term sustainability • The Chinese and Indian schemes benefit from government subsidy: • Rural Mutual Healthcare (China) • Self Employed Women association (India)

23. South African inequities

24. Reminder: The People we Serve Public Sector-Low Income ±37 million Affluent’: ?±0.5m Middle-Low Income ±11.5 million

25. Comparing Costs Real per capita pa Often used as demonstration of inequity in absolute and in trend terms Council for medical schemes reports, National and Provincial budget statements

26. South African inequities • The skewed distribution of financial resources between the public and private sectors in relation to the population served has led to inequities in the health system because the better-off segments of the population have better access to health services

27. What is needed for South Africa? Fair financing means that the risks that each household faces due to the cost of healthcare are distributed not according to the risk of illness (WHO) Will need trade offs if fairness is to be achieved Will need involvement of communities and all stakeholders across all spheres Will need improved governance structures and transparent, responsive and accountability systems across all spheres of government

28. What is needed for South Africa? • A shared value of universal coverage based on principles of • Fairness and without barriers • Social solidarity, promoting unity and ownership • Financial risk protection • Access, availability, acceptability, affordability, and quality • What should be the uniting and core elements: • Solidarity: the young must subsidise the old, the healthy must subsidise the sick and the rich must subsidise the poor

29. South Africa needs a healthcare house to accommodate all its citizens An estimated 8.2 million citizens have a private one The remaining estimated 41 million citizens cannot afford a private one

30. What is needed for South Africa? • Universal coverage so as to • provide a better level of financial risk protection against out-of-pocket payments and user fees at the point of utilizing needed health services for the entire population. • address the burden experienced by South African households of high medical scheme contributions and high out-of-pocket payments (including co-payments). • reduce health-related catastrophic expenditures that lead to household impoverishment. • address inequities in the health system this through pooling of resources.

31. THE FIRST 5 YEARS OF NHI • NHI will be phased-in over a period of 14 years • Will include piloting and complete overhaul of the health system in the following areas: • Quality improvement • PHC Re-engineering • Management of health facilities and health districts • Infrastructure development • Medical devices including equipment improvements • Human Resources planning, development and management • Improving Access to medicines • Strengthening of information management and systems support • Public sector health finance reform • Establishment of the National Health Insurance Fund in the latter years of the 1st phase

32. NHI PILOTS

33. 1st PHASE OF NHI PILOTS • The 1st phase occurring in the 1st 5years of rollout includes: • Strengthening of the health system and • Improving the service delivery platform • Addressing human resource for health gaps

34. NHI PILOTS IN 2012 / 2013 • The first steps towards implementation of National Health Insurance in 2012 will be through piloting • Pilots commenced on the prioritized health districts • 10 (+ 1) districts have been selected for piloting • They extend coverage for 11 million people • Pilot district selection has been based on the following criteria: • Demographic profile • Socio-economic profile • Burden of diseases using (MDG Proxy indicators) • Service delivery platform and health system performance • District management capacity to conduct pilots

35. Eden NHI Pilot District and the role of partners

37. Demographic profile of the District • Eden is one of the 6 districts in the Western Cape • The District covers a geographical area, of 22,720 square kilometres

38. Population Pyramid of the District

39. Demographic Data • Total Population (Midyear 2011 DHIS) 558,950 • Population density (Midyear 2011) 24.6/Km2 • Percentage of population with medical insurance (General Household Survey 2007) 14.9% • 49.5% of the population is in the age group 40-64 yrs followed by 25-39 yrs (31%)

40. Social Determinants of Health

41. Social Determinants of Health

42. Socio-economic indicators • According to the Community Survey 2007, 12.2% of the population are unemployed and 5% of households live with an annual income below R4, 800 or less than R400 per month. • The Deprivation Index of the district is 1.3

44. THANK YOU FOR YOUR ATTENTION