Health systems reform, equity, universal health coverage, and other challenges

1. Health systems reform, equity, universal health coverage, and other challenges Adam Wagstaff Development Research GroupThe World Bank

2. Are health systems trying to achieve these things? Yes • Better health outcomes – for everyone, not just the better off • Protection against the financial consequences of ill health and injury • Doing both these things efficiently – money wasted in the health sector could be spent on schools, improving the environment, culture, etc.! • Creating jobs. But health systems should not destroy jobs, especially formal-sector ones • Fostering a vibrant private sector • Increasing the role of the State • Boosting economic growth • Improving the balance of payments No

3. What’s universal coverage got to do with it? Instrument specified • Rights approach • By law everyone has the right to health (care) • Use courts? You need a health system, and resources! • Health insurance approach • x% of the population pays only y% of the cost at the point of use for z% of all possible services • Does UHC mean x=y=z=100? • Everyone should get the care they need (from a defined package) without experiencing financial hardship as a result • Focus is on ensuring people get the health care they need, without suffering financially • It comes close to our health system objective • It doesn’t specify the instruments to be used, though in practice, UHC reforms often employ UHC instruments! Instrument not specified

4. How do UHC instruments fare in getting us to UHC goals? • UHC countries don’t always do better in: • Ensuring people in equal need get the same irrespective of their ability-to-pay, or • Protecting people from catastrophic out-of-pocket spending • UHC reforms don’t always: • Push us toward the UHC goal • Push us much toward it when they do – even after UHC reforms, we’re typically a long way from being at our UHC goal! • Need to step back and think more broadly about the health system and our goals

5. PRO-RICH PRO-POOR

7. Before and after Vietnam’s “health insurance for the poor” reform

8. The situation after Indonesia’s “health insurance for the poor” reform

9. Flashpoints in the ongoing debate How should providers be paid? What other tools to be used to promote quality, efficiency, and equity? Passive payer? Or active purchaser? Exposed to risk? Competition? Insurers? One fund? What should it cover? Who should pay what? And how? Government fund(s) Insurer(s)/Purchaser(s)/Payer (s) Should public providers be autonomous? Over what? And compete with one another for contracts? And against private providers? Households/Patients Providers

10. Who should pay what? And how? • Taxes typically most progressive finance method • Social health insurance (SHI) being reconsidered: • In OECD, regressive; but also hurts formal-sector employment • Taxes being used to fund “insurance” cover for the poor, and near-poor, and even entire non-formal sector • Desire to reduce out-of-pocket spending, but barriers to higher taxes – so some services may require out-of-pocket payments!

11. One fund? What should it cover? • Desire to merge funds: • Linking entitlements to contributions creates (horizontal) inequities • Political economy is hard when benefit packages are different! • Benefits package a big issue • Differences between de jure and de facto coverage. Implicit – and probably inequitable – rationing! • Could rationing be made more explicit and fairer? • Getting the “better off” to pay something at the point of use, and everyone to pay something for some very costly interventions until GDP is “big enough”? But how to operationalize?

12. Purchaser-provider split popular, but debate about how to do it • “Coverage” expansion used as opportunity to move from directly-managed vertically integrated model to a purchaser-provider split • Debate about merits of contracting purchasing function to an insurer • And about merits of multiple competing insurers. Risk-selection rather than lowering admin. costs? Does competition raise costs? • A few countries have private insurers compete with one another for a contract to be the 3rd-payer for a specific geographic area for a specific time period • Where’s information on payer performance coming from? Who’s getting it?

13. How should providers be paid? What other tools to be used? • Shift away from budgets to performance-related payments, e.g. DRGs, P4P. But concerns about gaming, fraud, and costliness of sophisticated payment systems • Increasing use of sophisticated IT systems that allow the 3rd-party payer to hold providers accountable for quality of care, e.g. Rajiv Aarogyasri and RSB in India • Performance league tables – “naming and shaming” – also being tried

14. Autonomous public providers? Competing? Against private providers? • Government facilities haven’t always been granted the autonomy that’s required under a purchaser-provider split. But is autonomy good? • Does competition work? Depends whether prices fixed so competition is on quality? • Shifting to demand-side subsidies and consequent downsizing of public sector hard politically • Who monitors provider performance?

15. No blueprint for a health system • Confusion over whether UHC is an instrument or a goal • UHC instruments get us only so far toward UHC goals • Need to think more broadly, especially about health system goals, including efficiency • Multiple flashpoints in health system reform debate • Some agreement emerging • e.g. on shift to general revenues, defragmentation of schemes, non-reliance on budgets to pay providers • But plenty of disagreements too • e.g. competition among purchasers and providers, role of private sector, autonomy of public providers