Road to Universal Health Coverage

1. Road to Universal Health Coverage NAMAF 8th ANNUAL CONFERENCE Hilton Hotel, Windhoek 23 September 2014 Banda Ngaujake R&D Manager: Social Security Commission

2. AGENDA • UHC in Context • WHO Financing Options • 3-Part Strategy for realisation of UHC • Unacceptable trade-offs • Lessons from Japan – overall success factors and design success factors • Where to for Namibia? – the role of UHCAN

3. “Universal health coverage is the single most powerful concept that public health has to offer.” Dr. Margaret Chan, Director-General, World Health Organization

4. UHC IN CONTEXT • The aspiration to attain universal coverage is not new. Reference to it can be found in: WHO's constitution-1948; Alma-Ata Declaration-1978; World Health Report on Primary Health Care-2008 etc. • WHR topic based on World Health Assembly Resolution in 2005: The Resolution 58.33 defined “Universal Coverage” as coverage with: needed health services; financial risk protection; for everyone. • The resolution also states that universal (health) coverage cannot be achieved without a well-functioning health financing system.

5. UHC IN CONTEXT Overall objective of UHC: “ to promote equitable access to sustainable and optimum quality health care and providing increased financial protection for the people of Namibia”

6. UHC IN CONTEXT

7. WHO proposed financing options • The WHR-2010 proposes three inter-related health financing strategic options for universal coverage: - Raise sufficient funds for health: More money for health - Reduce heavy reliance on direct OOP: More equity for health. • Reduce and eliminate inefficient use of resources: More health for the money

8. Options for raising more domestic funds for health • Increase the priority given to health in government budget allocations • Raise revenue for health more efficiently – e.g. increase the total availability of resources (strong tax base) • Find new sources of domestic funds e.g. • Sin taxes

9. Options to reduce the impact of OOPs Options in addition to prepaid and pooled resources to ensure greater coverage and lower financial barriers: • Free or subsidized services (e.g. through exemptions or vouchers) for specific groups of people (i.e. the poor) or for specific health conditions (i.e. child or maternal care). • Subsidized or free insurance contributions for the poor and vulnerable. • Cash payments to cover for ex. transport costs for the poor.

10. Options to encourage greater efficiency • Paying providers: move away from fee for service if possible. Consider results-based payment where good monitoring is possible etc. • Medicines: improve prescribing guidance, training of staff; incentives for generic substitution; regulate promotional activities, more public information (irrational use) etc. • Health services/ governance: Provide more continuity of care, monitor hospital performance, improve regulatory capacity • Reduce duplication – avoid “fragmentation”

11. A three-part strategy for fair progressive realization of UHC: • Categorize services into priority classes. Relevant criteria include those related to cost-effectiveness, priority to the worse off, and financial risk protection. • First expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. • While doing so, ensure that disadvantaged groups are not left behind. These will often include low-income groups and rural populations.

12. Some trade-offs are generally unacceptable: • Unacceptable trade-off I: To expand coverage for low- or medium-priority services before there is near universal coverage for high-priority services. This includes reducing out-of-pocket payments for low- or medium-priority services before eliminating out-of-pocket payments for high-priority services.

13. Some trade-offs are generally unacceptable: • Unacceptable trade-off II: To expand coverage for well-off groups before doing so for worse-off groups when the costs and benefits are not vastly different.   • Unacceptable trade-off III: To give high priority to very costly services whose coverage will provide substantial financial protection when the health benefits are very small compared to alternative, less costly services.

14. Some trade-offs are generally unacceptable: • Unacceptable trade-off IV: To first include in the universal coverage scheme only those with the ability to pay and not include informal workers and the poor, even if such an approach would be easier. • Unacceptable trade-off V: To shift from out-of-pocket payment toward mandatory prepayment in a way that makes the financing system less progressive.

15. Lessons from Japan’s experience with UHC: Success factors  • Economic growth. Raising sufficient financial resource is critical. • Sense of solidarity. Social insurance can be more easily run in a society with a relatively large middle- income population and a very strong sense of equality. Japan had both when they were implementing UHC. • Strong political leadership. • Meticulous designing of the system • Accumulation of prior achievements in developing basic administrative systems.

16. Lessons from Japan’s experience with UHC: Design success factors  • Making a choice between the social health insurance-based model and the tax-based model. • Targeting the entire population or the majority. In the case of developing countries, it may be feasible to progressively expand the coverage of social insurance. • Setting up the range of services offered and the proportion of the costs covered. Once the range of service and the proportion of the costs covered are set up, reducing them would be very difficult, as it may provoke strong protests from service users.

17. Lessons from Japan’s experience with UHC: Design success factors  • Deciding whether or not the persons insured by private health insurance can be excluded from public health insurance. In theory, it would be better not to let private health insurance holders opt out from public health insurance, however, such decision may provoke a political backlash. • Ensuring the efficient and effective administration. Information systems management critical here.

18. Where to for Namibia? The role of UHCAN •  In order to address the issue of Universal Health Coverage, Namibia has established the Universal Health Coverage Advisory Committee of Namibia (UHCAN) • The objective of UHCAN is to provide advice and guidance to the Ministry of Health and Social Services, on the development of systems and policies for UHC in Namibia with focus on evidences and alternatives.

19. Illustrative questions that will be addressed by UHCAN include: • What type of funding and administration system will be most suitable in the Namibian context? • What benefit package is affordable?  How will this be determined? Or will there be a differential benefit package according to insurance contributions, with a limited mandatory package providing the base? • How will system be funded and resources mobilised? Consideration could be given towards insurance premiums, taxes, corporate social responsibility, solidarity tax, community funds or philanthropy etc.

20. Illustrative questions that will be addressed by UHCAN include: d. What will be the role of public and private providers under the new system?  To what extent will public and private providers rely on insurance financing (e.g.; Will insurance financing replace some existing direct budget payments for Ministry of Health and Social Services facilities?)  e. What principles should govern provider payment in the new system?

21. Proposed Workplan 1. Ensure national ownership and wide representation Review and Approve Terms of Reference for UHCAN Approve Terms of Reference for UHCAN Prioritise and rank issues for stakeholders 2. Develop the strategy and roadmap towards UHC Recruit Health Economist 3. Learn from experiences of other countries Develop synopses of potential countries to be visited Select countries to be visited

22. Proposed Workplan 4. Design the Financing Model Conduct the Health Financing Review 5. Supporting the process towards UHC Determine gap between current status and selected UHC model Conduct appraisal of options of implementation Develop detailed implementation strategy and plan

23. THANK YOU & QUESTIONS