Evaluating and improving health systems: achieving ...€¦ · A history of user charges:...

Evaluating and improving health systems:

achieving Universal Health Coverage in low- and middle-income

countries

Reinhard Busse, Prof. Dr. med. MPHDepartment of Health Care Management

Berlin University of Technology

(WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies

• What do we mean by coverage?

• What is “universal health coverage”?

• UHC and the broader Health System Performance Assessment

• Roads to achieve UHC – and the equity component

• Monitoring progress towards sustainable development

2RKI / Berlin, 20.06.2019 Evaluating and improving health systems for UHC

>10 years ago: how to visualize coverage?

The first Coverage Cube was born (still descriptive-analytical) …

universal

comprehensive

free at thepoint of service

… picked up by WHO only a year later (and becoming normative) …

Note: since then, “universal” has been applied to all three dimensions …

… and again in 2010 (being applied to UHC)

The goal of universal health coverage is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship.

It involves coverage with good health services (scope) as well as coverage with a form of financial risk protection (depth). A third feature is universality – coverage should be for everyone (breadth).

What is univeral health coverage?

RKI / Berlin, 20.06.2019 Evaluating and improving health systems for UHC

WHO Health Report (2015) Tracking universal health coverage. First global monitoring report

Note: “quality” added = UHC

performance

Health Systems Performance Assessment – my framework

Access(ibility)Quality

(for those who receiveservices)

Outcomes=x

“Improved health”

“Responsiveness”/ “patient experience”

Health Systems Performance Assessment – my framework

Access(ibility)Quality

(for those who receiveservices)

Resources(money, personnell etc.)

Health system performance

Outcomes

Efficiency

10Evaluating and improving health systems for UHCRKI / Berlin, 20.06.2019

ROADS TO ACHIEVE UHC –AND THE EQUITY COMPONENT

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Evaluating and improving health systems for UHC

Not covered

“Coverage” by access to tax-financedprovision or insurance coverage

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VHI = voluntary private health insuranceSHI = social healthinsurance

POPULATION COVERAGECoverage by income in a typical middle-income country

Result: Fragmented systems (uncovered not shown)

Providersoften separate

for differentsegments

Population

GovernmentSickness funds

Private insurance+CBHI

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Not covered

“Coverage” by access to tax-financedprovision or insurance coverage

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Two ways to expand coverage:

Need to extend coverage by (1) extending tax-financed coverage or …

(2) extending the SHI system

African countries with health coverage programs for …

Contributory programs

Tax-financed programs Tax-financed programs

SHI: looking at population coverage by income quintiles

Vietnamas an exampleof missing middle

(early) Ghanaas an example of an

immature pro-rich system

Thailand without a missing middle (but rich partly excluded)

Population coverage in low and middle-income countries (by income inquintile) – an example I

Population coverage in low and middle-income countries (by income inquintile) – an example II

Countries with betteraverages have (relatively)small inequities between

income groups …

Population coverage in low and middle-income countries (by income inquintile) – an example III

… while countries with worseaverages have large inequities

between income groups!

Population coverage in low and middle-income countries (by income inquintile) – an example IV

Differences for poor across countries are larger than for rich!

SERVICE COVERAGEWhat is (not) covered?

Basic Benefit Package (% of countries with no user fees for each intervention)

Defining the benefit package – globally applicable

“All” possiblehealth benefits

Covered benefit categories

Actual benefits

Representativeinstitutions, e.g.

Parliaments (Law)

Planning Bodies Coverage Commissions

using HTA

Criteria

• Economic crises in many developing countries in the 1980s

• Washington consensus

– Reduce public expenditures

– Introduce market based reforms

– Strongly promoted by World Bank and IMF, demanding structuraladjustment programs

COST COVERAGEA history of user charges: background

• Health care quality in public sector is bad

User charges can improve resource availability at providers(availabiltiy of medications, materials)

Can improve quality

Will increase public health service utilisation

• User charges can reduce costs and improve efficiency ofresource use

too much focus on hospital care

will free resources for basic services and for the poor whoshould be exempted

World Bank arguments (back in the 1990s)

But the assessment (and the advice) has changed:User fee policies around 2000 and their reforms in Africa

41 countries

37 countries

4 countries

Countries Charging User Fees in Public Clinics and Hospitals (%)

UHC AND WIDER HEALTH SYSTEM PERFORMANCE

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But good coverage ≠ good access

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Need (by socio-economic status, ethnicity/ migration status etc.)

x Quality = Outcomes

Unmetneed

Realisedaccess

coverage (financial issues)

availability of care

waiting, acceptability etc.

Services reported to be offered by facilities in 17 African countries, 2013-2017: even if covered, many services are not available!

availability of care

Source: SARA surveys on “readiness” (WHO Afro 2017)

General service “readiness” in 17 African countries, 2013-2017:even if covered and available, quality & safety are inferior

x Quality (here: structure/ process)Source: SARA surveys on “readiness” (WHO Afro 2017)

e.g.Electricity

WaterPhone

Internet

e.g.Scale

ThermometerStethoscope

e.g.Haemoglobin

Malaria

• SDG 3.8: Achieve UHC, including financial risk protection, access to quality essential health-care services and access to […] essential medicinces and vaccines for all

• Indicators

3.8.1: Coverage of essential health services

3.8.2: Financial protection when using health services

(originally: number of people covered by health insurance or a public health system per 1,000 population)

Monitoring Achievement of UHC as part of SDGs

• Ideally:

– Measure effective coverage (proportion of people in need of services who receive services of sufficient quality to obtain potential health gains)

– Include range of services (promotion, prevention, curative services, rehabilitation, palliation)

– Cover main health areas (Reproductive/ maternal/ neonatal/ child health, infectious and non-communicable diseases, injuries)

– Disaggregate index for inequality dimensions

De facto a measure of coverage, availability and quality

Measuring coverage of essential health services

Selection based on:

• Relevance (disease burden, available interventions)

• Measurable coverage andclear target

• Data availability acrosscountries (also for equityanalysis)

• Easy to communicate

Data on inpatientand outpatientservice use is

unavailable for LMIC

Data on coveragewith diabetes

care unvailable

Calculating the UHC service coverage index

The result: but where is the problem in low-scoring counries?

UHC service coverage by region and subindices

• Catastrophic spending on health SDG indicator 3.8.2

– Proportion of the population with large household expenditure on health as a share of total household expenditure or income (e.g. greater than 10% or 25%)

• Impoverishing spending on health related to SDG 1.1.1

– Out-of-pocket spending pushes households below the poverty line (here: $1.90 or $3.10).

Measuring financial protection

Catastrophic health spending worldwide

Impoverishment due to out-of-pocket spending

THE CONTRIBUTION OFUNIVERSAL HEALTH CARE TOSUSTAINABLE DEVELOPMENT

At least as important:

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For individuals: poverty in informal sector

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For society: economic growth

• The understanding of UHC has become broader, possibly making it more difficult to understand

• Important for both researchers and policy-makers alike to understand its dimensions: population, service + cost coverage (the “cube”) + availability + quality “effective coverage” (as part of wider performance)

• To achieve UHC, (1) indicators to measure each dimension are required, (2) data have to be collected, (3) the situation has to be critically assessed and compared, (4) good practice based on evidence from elsewhere should be implemented and (5) progress has to be monitored and policies adapted accordingly

Conclusions/ take-home messages

Evaluating and improving health systems: achieving ...€¦ · A history of user charges:...

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