module, 6-15 November 2019 Moving from fragmented systems ... · Population 3 Week 1 –what we...

Health Care Financingmodule, 6-15 November 2019

* Department of Health Care Management (WHO Collaborating Centre for Health Systems Research and Management), Technische Universität Berlin, Germany & European Observatory on Health Systems and Policies** School of Public Health, KNUST, Kumasi, Ghana

Moving from fragmentedsystems to Universal Health Coverage

Reinhard Busse*

Peter Agyei Bafour**

211 November 2019 From fragmented systems to UHC

Pathway to UHC: globally and in Africa– very usreful books to read

Population

3

Week 1 – what we have covered so far …


Fri 8.11.

Tax-funded systems

Social Health Insurance

Thu 7.11. Fri 8.11.

Private insurance and CBHI

… but that assumpted countries have one or the other …

Providers:often separate

for differentsegments

Population

Private Insurance


… while in reality different sub-systems exist next to each other = “Fragmented system”

Rich

Formalsector

Poor

Sickness fundsGovernment+CBHI

Tax-fundedsub-system for poor

SHI sub-system forformal sector

PHI sub-system for rich

Funding Taxes Contributions Premiums

Collector Government Sickness funds Private insurers

Pooling Yes varying No

Purchaser MoH Sickness funds None

Purchasing Integrated Contracts None

Provider MoHinstitutions

Contracted public& private providers

Private providers

Basic characteristics of sub-systems in fragmented systems

11 November 2019 From fragmented systems to UHC 5


Coverage in countries with fragmentedsystems: assuming a country has 100% coverage but within different sub-systems …

Poor

Formal sector

Rich


… but it will be more liekely look like this - with a part of the population uncovered

Poor

Formal sector

Rich


Population coverage in 2011: large gaps in Africa and southern Asia


Two pathways to expand coverage

VHI

SHI

Not covered

Tax


Need to extend coverage

→ by (1) extending tax-financed coverage or …


(2) extending the SHI system


Achieving universal population coveragehas often taken long … but may go quickly

15

Population coverage by incomequintiles: missing middle?

Vietnamas an example

of missing middle(early) Ghanaas an example of an

immature pro-rich system

Thailand without a missing middle (but rich partly excluded)


176 November 2019 Frameworks and concepts for analysis11 November 2019 From fragmented systems to UHC


African countries with health coverageprogrammes for …

Afr

ican

Contributory programs

Tax-financed programs

Tax-financed programs


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

Afr

ican


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

Afr

ican


User fee policies around 2000 and theirreforms in Africa

41 countries37 countries

Main advantages

▪ automatic population coverage

▪ broad revenue base

▪ equity of financing?

▪ enables trade-offs between spending priorities

▪ tight cost control

▪ responsibility for population health in the hands of gov’t

▪ democratic accountability

Pros and cons of tax-funded systems

Main disadvantages

▪ funding depends on fiscal space

▪ funding depends on political priorities

▪ regional inequity in case of decentralized revenue generation/pooling/purchasing

▪ often weak purchasing arrangements

▪ still less choice

▪ political decision-making


Main advantages

▪ legal entitlement to benefits

▪ more choice

▪ of payer

▪ of provider

▪ free access: “every patient is a private patient”

▪ financing more transparent?

▪ less political interference?

Pros and cons of SHI systems

Main disadvantages

▪ difficult to implement with large informal sector

▪ contributions levied on wages not income

▪ coverage limited to curative services?

▪ tax revenues still important – up to 40%!

▪ administrative complexity


Main advantages

▪ may develop with relatively little government intervention

Pros and cons of VHI systems

Main disadvantages

▪ does not achieve significant population coverage

▪ access and affordability problems are inevitable

▪ difficult to regulate in a way that it contributes to UHC →make mandatory



Pros and cons of CBHI

Positive - Improved access for members- Improved financial protection for members- Builds local (administrative/managerial) capacity- Includes informal sector- Very transaprent (local control)

Negative - Low population coverage- Voluntary insurance → adverse selection- Exclusion of the poor (high premiums) - Limited financial protection (only basic services –insufficient resources)-Risk of increasing inequities

Source: Ekman 2004

→ Step in the direction of UHC?

module, 6-15 November 2019 Moving from fragmented systems ... · Population 3 Week 1 –what we...

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