health financing and financial protection in the americas

Health Financing and Financial Protection

in the Americas

Working Paper prepared by the WHO Regional Office for the Americas

AMRO/PAHO

Production: Phoenix Design Aid A/S, Denmark

Design: FFW Ltd

1 This paper is a summary of the Chapter 1, Section 6, of Health in the Americas 2017, with some updates and modifications. The new contribution is focused in financial protection and the analysis of new information about this issue.

Conference copy for consultation

WHO/HIS/HGF/HFWorkingPaper/17.9

© World Health Organization, 2017 All rights reserved.

This is a working paper prepared for the Universal Health Coverage Forum,

Tokyo, Japan, 2017. This document may not be reviewed, abstracted, quot-

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Health Financing and Financial Protection

in the Americas1

AMRO/PAHO

Working Paper prepared by the WHO Regional Office for the Americas

Health Financing and Financial Protection in the Americas

ii

Acknowledgements

The paper was developed by Camilo Cid (regional advisor and focal point in health

economics and financing) , Claudia Pescetto (regional advisor in health economics

and financing), Juan Pablo Pagano (Consultant, health economics and financing),

Amalia Del Riego (unit chief health services and access unit), and James Fitzgerald

(Department Director) from the Department of Health Systems and Services of the

Pan American Health Organization/World Health Organization.

Valuable comments have been received from Gabriela Flores, Matthew Jowett and

Joseph Kutzin (WHO).

CONFERENCE PAPER

iii

1. INTRODUCTION .....................................................................................................1

2. FINANCING HEALTH IN THE AMERICAS .......................................................... 3

2.1 Public expenditure in health.................................................................................4

2.2 Out-of-pocket health expenditure .....................................................................7

2.3 Financial protection ...............................................................................................10

3. DISCUSSION AND CHALLENGES .....................................................................15

3.1 increasing public investment: a priority need ............................................. 15

3.2 more efficiency: necessary, but not enough ................................................ 17

3.3 improving financial protection through pooled funding ......................... 18

4. CONCLUSION .................................................................................................... 20

REFERENCES ...........................................................................................................21

Table of contents

CONFERENCE PAPER1. InTRODuCTIOn

1

Despite the progress in addressing health in the

Americas, exclusion and lack of access to quality

services persist for large sectors of the population.

An estimated 30% of the population has no access

to health care for financial reasons, and 21% is kept

from seeking by geographic barriers (1). At the

global level, In 2010 an estimated 103 million people

incurred out-of-pocket payments exceeding 10% of

households total consumption or income (11.1% of the

population in the region) and 17.5 million incurred it

at the 25% threshold (1.9% of the population). (2)

The prevailing models of care, based more on hospi-

tal care for episodes of acute illness than on compre-

hensive health care, including disease prevention and

health promotion, often with excessive use of tech-

nologies, weak primary care services, and poor distri-

bution of human resources (physicians, nurses, and

others), do not necessarily meet the health needs of

people and communities As an example, data shows

sustained high rates of total hospitalizations for am-

bulatory care-sensitive conditions in some countries

of the Region like Argentina (18%) and Colombia

(22%) (3). Investments to reform and improve health

systems have not always been designed to deal with

new challenges related largely to the demographic

and epidemiological transition, social and economic

changes, or the evolving expectations of the popula-

tion.

Lack of universality and equity in access to quality

services and appropriate coverage, entails a substan-

tial social cost and increases the risk of impoverish-

ment of population groups in highest conditions of

vulnerability. The evidence shows that when there

are access barriers to services (whether economic,

geographic, cultural, demographic, gender, ethnic or

age related, or other), deterioration in health implies

not only greater expenditure but a loss of income as

well. The absence of mechanisms to protect against

the financial risk of ill health creates and perpetuates

a vicious cycle of disease and poverty.

Insufficient financing and inefficient allocation and

use of the available resources for health are major

obstacles to progress toward equity and financial

protection. For example, if we take life expectancy as

an overall indicator of health status and take public

expenditure in health as one of its determinants, as

seen in other studies (4) in the Region of the Amer-

icas two countries like Chile and the United States

can reach similar levels of life expectancy (79.5

years) with very different levels of public expenditure

in health as a percentage of the GDP (3.9 and 8.3

respectively) indicating potential sources of inef-

ficiencies in public expenditure (3). Indeed, aver-

age public health expenditure in the Region of the

Americas is very low compared with the countries

of the Organisation for Economic Co operation and

Development (OECD) (5, 6). Still, the largest share of

available resources is highly concentrated in hospital

curative and specialized care rather than in preven-

tive and promotion activities at the first level of care.

Direct payment or out-of-pocket expenditure (OOP)

at the point of service, the most inefficient and re-

gressive form of financing, yields an unstable flow of

financial resources and constitutes an access barrier

that impedes or delays care and makes it more ex-

pensive for both users and the health system (7, 8).

Furthermore, it has a relatively greater impact on the

poor, as even the smallest payment can represent a

substantial portion of their budget, making it highly

regressive and inequitable. (12)

The strategy for universal access to health and

universal health coverage (1) of the Pan American

Health Organization (PAHO) redefined the concept

of coverage and access to health and stressed the

values of the right to health, equity and solidarity;

it also recognized financing as a necessary, though

insufficient, factor in reducing inequities and increas-

ing financial protection for the population.

1. Introduction


2

The core value in the strategy’s definition of “access,” embraced as a priority for

society as a whole, is “the right to health,” which requires adequate, allocated, and

efficiently managed financing.

This vision stands in sharp contrast to the traditional view, in which access to cer-

tain services depended on an individual’s and household’s ability to pay and went

hand in hand with the proposals to adopt direct payments and the promotion of

policies that had led to the fragmentation of health systems in previous decades.

At least part of these policies stemmed from recommendations found in reports

from multilateral agencies (9). At the same time, the strategy acknowledges the

need to foster the necessary changes through political and social action that puts

health squarely at the center of the policy agenda.

Strategic Line 3 of the strategy calls for “Increasing and improving financing, with

equity and efficiency, and advancing toward the elimination of direct payment that

constitutes a barrier to access at the point of service.” Three interrelated lines of

action flow from this:

• Increase financial protection by eliminating direct payment, which constitutes an

access barrier, thus preventing exposure to catastrophic expenditures or those

that lead to or exacerbate poverty. The replacement of direct payment as a

financial mechanism should be planned and progressively achieved through pre-

paid pooling mechanisms, using sources of funding that guarantee their stability

and sustainability.

• Increase public health expenditure to the benchmark of 6% of GDP, which im-

plies a commitment by society as a whole to increase the fiscal space for health

in terms of new public sources of financing, with the search for equity as the

main objective.

• Boost efficiency in the health system by adopting a series of measures that spe-

cifically impact its financing and organization, such as aligning payment mech-

anisms with health system objectives, deploying human resources accordingly

and with the right skills-mix and rationalizing the introduction of new medicines

and other health technologies that contribute significantly to rising health ex-

penditures.

Countries in the Region of the Americas have not remained indifferent to the chal-

lenges they face and have adopted different policies to address them. The commit-

ments made in 2015 with the launching of the UN Sustainable Development Goals,

among which the goal of universal access and the measure of financial protection

as one of its indicators, reinforce these efforts.

This paper shows an overview of the health system financing situation in the Re-

gion and the advances and challenges they still face under the lens of Universal

health objectives. Following this introduction, health financing in the Region will

be examined in a conceptual and descriptive section, with special attention to

financial protection. The third and final section discusses the immediate challeng-

es facing the countries in terms of the need to equitably and efficiently increase

financing with financial protection.

CONFERENCE PAPER2. FInAnCIng HeAlTH In THe AMeRICAS

3

The financing of health systems in the Americas rely on a variety of revenue sources

linked to the nature of the different arrangements to cover and improve access to health

services for the overall population. In general, there is a clear predominance of pub-

lic funding sources mirroring the prevailing mix of models linked to employment (e.g.

social health insurance) and entitlement based on legal residence (e.g. national health

services) along with specific schemes put in place to cover and financially protect the

most vulnerable, the unemployed and the informally employed.

General government and social security funds prevail as the main financing agents

through both specific budget-line allocations and transfers out of general revenues, and

social (employer/employees) contributions respectively, with some exceptions where

external and direct payments at the time of service play the biggest role.

Figure 1: Segmented health systems reflected in the financing

2. Financing health in the Americas

Social security funds General government revenue

Out-of-pocket expenditure Private insurance Other private

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Sources: PAHO/WHO 2017, Health in the Americas. (13)

100%

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4

External funding (from international agencies, donors, foundations, etc.) and

other private sources are only relevant in few countries and mainly linked to the

funding of priority programs (i.e. HIV/AIDS, Tuberculosis, malaria and vaccina-

tion), whose long-term financial sustainability is at stake.

Pooled resource arrangements, in turn, are usually long-term and have also taken

shape during the historical development of the systems. The Region is largely

characterized separate sub-systems built around specific population groups with

little or no solidarity across these.

On the other hand, the purchase of services as a resource allocation mechanism

takes many forms, with historical budgets in the public sector and fee-for-service

payments in the private sector predominating (10).

In the majority of the countries, operational financing decisions are made year-

to-year by the ministries of finance and health as part of a planning process in

which the democratic political system is involved, since in most cases, the main

source of funding (or a significant part of it) – the budget – is approved by the

parliament or congress. Other sources of financing are determined by the market

through private expenditure.

Total per capita health expenditure in the Region averages 1,320 international dol-

lars (Intl$) per year (adjusted by purchasing power parity) and ranges from Intl$

160 in Haiti to Intl$ 9,145 in the United States. Factoring out the United States

and Canada, the value falls to Intl$ 1,113. This absolute level of expenditure can

be compared with the average for the OECD countries, which is three times that

of the Region and far less scattered. Furthermore, in each country the different

segments present very different per capita expenditures, one of the most relevant

signs of inequity and segmentation. For example, in El Salvador, per capita health

expenditure in affiliates to the Institute of Magisterial Welfare 2 was four times

that of users of general public health services through the Ministry of Health, with

per capita expenditure in the general regime of social security standing almost

exactly in the middle of both extremes, at least until 2011 (11). However, in the last

years the country is advancing towards closing these gaps in an effort to reduce

inequities. Other countries are also making efforts in the same direction, but

slowly, as seen in Colombia and Chile. With the reform of 2008, Uruguay’s transi-

tion was faster in closing this gap, leading to a drop in the difference between the

per capita expenditure of mutual private providers and the main public provider

from 2.3 times greater in 2007 to just 25% greater in 2012.

2.1 Public expenditure in health Considering the universal health strategy’s public health expenditure benchmark

of at least 6% of GDP 3, Figure 2 shows that only 5 of the 34 countries that pro-

vided information are above that threshold: Canada, Costa Rica, Cuba, the United

States, and Uruguay. The countries below the threshold include three with public

health expenditure above 5% of GDP: Colombia (5.4%), Nicaragua (5.1%), and

Panama (5.9%).

2 Translation from Spanish “Instituto Salvadoreño de Bienestar Magisterial”3 While this indicator is very important because it is a significant measurement of country efforts in health and because of its acceptance as a prerequisite and useful benchmark in the regional strategy for universal health, it cannot be interpreted in isolation, since individual variations can reflect movements within a country’s economic cycle (variations in GDP), for example, regardless of the resources allocated to the health sector.

$76

5

COnFeRenCe PAPeR2. FInAnCIng HeAlTH In THe AMeRICAS

Observing what happens with total health expenditure and its public-private mix, we discov-

er that in countries that exceed the 6% benchmark, public health expenditure accounts for

more than 70% of total health expenditure, except in the United States.

Furthermore, in the case of Bolivia, Canada, Colombia, Costa Rica, Panama, and Uruguay, this

balance is similar to the average for the OECD member countries (73%). At 17%, total health

expenditure in relation to GDP in the United States is known to be the highest in the world,

without proportionally better health outcomes (14). This indicates the need not only for more

resources but greater efficiency in their use.

At the opposite extreme, countries with lower public health expenditure are also those in

which the composition of total health expenditure is more skewed toward the private com-

ponent: Guatemala (private expenditure of 62%), Haiti (79%), Saint Kitts and Nevis (58%),

and Venezuela (71%).

However, Peru and the Dominican Republic are examples of the opposite, with low public

health expenditure (3.3% and 2.9% of GDP, respectively) and a high share of public health

expenditure in total health expenditure (61% and 67%, respectively). Added to this is the case

of the United States, with high public health expenditure (8.3%), but health expenditure that

is predominantly private (52%).

Figure 2. Health expenditure as a percentage of GDP and composition public-private, as a percentage of total expenditure, 2014

Figure 3 presents data on fiscal capacity in the Americas, and the average for EU countries.

The median for the Region, around 30% of GDP, stands in marked contrast to the average

of 48% of GDP for total public expenditure in the EU countries. Fiscal capacity (understood

as total public-sector resource mobilization) should be a potential source of fiscal space for

health in the Region. Furthermore, the combination of a low tax burden and weaknesses in

tax collection—manifested, for example, in tax evasion, elusion and tax fraud—create a sce-

nario not uncommon in the Region that must be considered in the specific analyses.

General government Private

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Sources: PAHO/WHO 2017, Health in the Americas.

71 7958 62 45 48 54

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29 21 42 38 55 52 46 67 52 59 54 52 61 46 54 69 68 46 49 6751 51 66 46 49 72 64 56 75

73 7173 73

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6

Figure 3. Fiscal capacity in the Region of the Americas, 2014 and UE average

When analyzing the fiscal priority of health in the Re-

gion (Figure 4), the variability of the indicator is even

greater. While public expenditure in health in the EU

member countries averages 14% of total public expen-

diture, almost half the countries in the Region of the

Americas give higher priority to the health sector. In the

case of Costa Rica and Nicaragua, for example, public

expenditure in health accounts for almost one quarter

of total public expenditure (23% and 24%, respectively).

At the opposite extreme, however, nine countries

allocate less than 10% of their total budget to the

health sector: Haiti (5%), Venezuela (5.8%), Bra-

zil (6.8%), Saint Kitts and Nevis (6.9%), Argentina

(6.9%), Trinidad and Tobago (7.6%), Jamaica (8.1%),

Grenada (9.2%), and Guyana (9.4%).

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Source: PAHO/WHO 2017, Health in the Americas.

50

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40

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Total public expenditure as a percentage of GDP

Figure 4. Fiscal priority of health in the Region of the Americas, 2014 and UE average

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Public health expenditure as a percentage to total public expenditure

7


Painting a more complete picture of the countries’ health financing efforts requires at least this dual

perspective in order to see how countries that prioritize health in their budget may be spending little

due to their excessively low level of total public expenditure, while countries with a high level of total

public expenditure may not be prioritizing the health sector, even though health expenditure figures

are relatively high in absolute terms.

Combining the data on fiscal capacity and fiscal priority reveals very unequal country performance.

For example, despite its relatively low fiscal capacity (25% of GDP), public health expenditure in

Nicaragua is relatively high for the Region (5.1% of GDP), thanks to the high priority of health in the

national budget (24% of total public expenditure). However, in Guatemala, where the fiscal priority of

health is relatively high for the Region (17.8% of total public expenditure), public health expenditure is

low (2.3% of GDP), due to the country’s excessively low fiscal capacity (13.4% of GDP, the lowest in the

Region).

In Brazil, public health expenditure stands at 3.8% of GDP, despite a high fiscal capacity (almost 40%

of GDP), since health has a low fiscal priority (6.8%). In general, the data show that in the eight coun-

tries where public health expenditure exceeds 5% of GDP (Canada, Colombia, Costa Rica, Cuba, the

United States, Nicaragua, Panama, and Uruguay) the fiscal priority of health is more than 14% of public

expenditure.

2.2 Out-of-pocket health expenditureWhen examining the impact of health expenditure on household well-being and access and use of

health services, out-of-pocket health expenditure merits special attention. This type of payment is re-

quired at the moment of use of services and generally at the point of service and includes any kind of

cost-sharing (in the presence of insurance), full payment (if no insurance), formal or informal. It should

be measured net of ex-post reimbursements and excludes any form of prepayment such as insurance

premiums.

The fact that this type of payment may be required to receive care or access the necessary health

services makes them a health care access barrier. Even among people who can cover these expenses,

incurring them may adversely affect their household’s well being and the consumption of other goods

and services or may even be harmful to health if the alternative is avoiding medical care.

It also has implications for the efficiency of the health system, since by discouraging the use of the

health services, it deters care seeking to more advanced stages of an illness, requiring more complex

and expensive services at later more expensive stages of illness.

Thus, out of pocket expenditure can result in access barriers to households and higher costs to the

health system in the medium and long term, together with worse health outcomes, poorer health sys-

tem response capacity, and lower efficiency and effectiveness.


8

Figure 4 shows the value of the indicator OOP as a percentage of total health ex-

penditure for the countries of the Region and, as a reference, the average for the

countries of the European Union (EU). 4 First, it shows that while out-of-pocket

health expenditure in the EU countries averages 21% of total health expenditure,

29 countries in the Region (83%) exceed that value.

Furthermore, countries with a lower proportion of out of pocket health expen-

diture are also those with higher public health expenditure (as a percentage of

GDP) (Figure 1): Canada, Colombia, Cuba, the United States, and Uruguay. Some

exceptions are conspicuous: Suriname has low public health expenditure (2.9% of

GDP) and also a low proportion of out-of-pocket expenditure (11% of total health

expenditure); and Costa Rica, with very high public health expenditure for the

Region (6.8% of GDP), has a moderate proportion of out of pocket expenditure

(25% of total health expenditure).

Low out-of-pocket expenditure is not always an indication of equitable access,

since it may also be due to lack of access to the services. Also, it can sometimes

increase with the desired increase in access, although the ratio with coinsurance

rates or unit values of copayment remains constant. For example, Colombia and

the United States show relatively high levels of population coverage for the peri-

od 2010-2015 (around 95 and 90% respectively) but with still relatively high levels

of people reporting monetary barriers to access care (29 and 37% respectively)

and even increasing in the period for Colombia (3)

Figure 5. Proportion of out-of-pocket health expenditure as a % of total health expenditures in the Region of the Americas, 2014

4 European Union parameters are used as representative of the more advanced countries, even though development levels in some EU countries are considered similar to those of several countries in the Americas.

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Out-of-pocket health expenditure as a percentage of total health expenditure

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9

The weight of direct payment (out of-pocket expenditure) by households in total

health expenditure is trending downward in certain countries in the Region, among

them Chile, Colombia, El Salvador, and Mexico (Figure 6).

Here, the case of El Salvador is worth examining (Figure 6). In 1995, more than 60%

of its health expenditure was financed through direct payments; today, the figure is

less than 30% and though still high, represents a significant decline. In Colombia, the

indicator fell from 38% to 15% in that same period, and the country currently has one

of the lowest percentages of out-of-pocket expenditure in the Region. Other countries

show certain stability in the indicator and remain at very high levels, as in Guatemala

(above 52% throughout the period), or low levels, as in Costa Rica, although with a

certain upward trend (from 21% to 25% during the period) (Figure 6).

In Ecuador, a marked increase in the indicator was observed between 1995 and 2000

(moving from 32% to 62%), subsequently shifting downward, but nevertheless remain-

ing at very high levels (48% in 2014).

Figure 6. Trends in out-of-pocket health expenditure in the Americas, 1995–2014 (selected countries)

Argentina

Bahamas

Bolivia

Brasil

Chile

Colombia

Costa Rica

Ecuador

El Salvador

Guatemala

Jamaica

México

Nicaragua

Panama

Perú

América Latinay el Caribe

199

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6

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7

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1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

2010

2011

2012

2013

2014


70

60

50

40

30

20

10

0


10

2.3 Financial protectionOut-of-pocket expenditure is generally more of a direct barrier to care for house-

holds with lower purchasing power, but it can also be one for the middle class

(15). Thus, having access to health services does not prevent out-of-pocket pay-

ments from undermining health equity, since “overcoming” the barrier can signifi-

cantly jeopardize a household’s well-being, driving it into poverty (impoverishing

expenditure) or exceeding a given proportion of its total expenditure or ability to

pay (catastrophic expenditure).

Expenditure is considered impoverishing for a household when it represents the

difference between being above or below the poverty line (16). Different poverty

lines can be used. Expenditure is considered catastrophic when out-of-pocket

health expenditure represents a substantial percentage of household expendi-

ture––usually 30% or 40% 5 of its ability to pay (12, 13), or 10% or 25% of total

expenditure or income (17, 2), with “ability to pay” understood as total household

income (measured as total household expenditure) minus the expenditure neces-

sary for meeting basic subsistence needs (20, 21). The incidence of catastrophic

and impoverishing expenditure indicators vary with the methodology used, as dif-

ferent poverty lines can be used to assess the extent of impoverishment in each

country and regionally.

However, a recent PAHO study with data within the period 2004-2015 (22) for 11

countries in the region shows that in 7 of them, 2.5% of households have cata-

strophic expenditures, regardless of the methodology used. These methodol-

ogies use different catastrophe thresholds, based on the measure of ability to

pay. Hence, some use a threshold of 30% or 40% of a household’s ability to pay

because they discount basic needs. More recently, within the SDG monitoring

framework two thresholds are used to define catastrophic expenditures (10% and

25% of total household expenditure.

Regardless of the methodological differences of the primary sources of data

and considering the 25% threshold, 6 of the 11 countries face catastrophic ex-

penditures in over 2% of households, while only Costa Rica and Uruguay have an

incidence below 1% (Table 1). Over 1% of households in Guatemala and Nicaragua

incur in impoverishing health expenditures when considering the USD1.90 per day

poverty threshold, while in Bolivia and Peru it is above 0.5%.

Countries can be classified into three groups (Table 1). In one group, Uruguay,

Panama, Mexico, Costa Rica and Bolivia have an incidence of catastrophic health

expenditure in less than 2% of households (less than 8% for the 10% threshold),

but Mexico and Bolivia have an impoverishing expenditure above 0.5%. In another

group, Chile, Argentina, Peru, and Nicaragua show an incidence of catastrophic

expenditures between 2% and 4%, (10-15% for the 10% threshold) but with high

variance in the incidence of impoverishing expenditures: Chile and Argentina

face a negligible incidence of impoverishing expenditures, while Peru and Nicara-

gua show an incidence above 0.5% (Nicaragua reaches 1.2%). Finally, in the third

group, Guatemala and Ecuador have a high incidence of catastrophic and impov-

erishing expenditure.

5 There is no absolute consensus regarding a threshold. For example, Wagstaff and van Doorslaer (18) examine threshold differenc-es in the case of Vietnam. Knaul et al. (19) define a threshold of 30% of the non subsistence expenditure or the total expenditure of a household once the international poverty line of US$ 1 per day is discounted.


11

Country Catastrophic Health

expenditure (SDg

indicator 3.8.2,

25% threshold) In %

Catastrophic Health

expenditure (SDg

indicator 3.8.2, 10%

threshold) In %

Impoverishing

Health expenditure

(uSD1,90 per day in

2011 PPPs) In %

Survey year

Argentina 2.518 10.890 0.007 2012-2013

Bolivia 1.403 6.612 0.616 2014

Chile 2.31 12.230 0.000 2012

Costa Rica 0.833 5.182 0.021 2013

ecuador 4.453 20.430 0.453 2011-2012

guatemala 4.149 11.781 1.076 2014

Mexico 1.324 4.658 0.230 2014

nicaragua 3.239 14.982 1.218 2014

Panama 1.301 6.280 0.018 2007-2008

Peru 2.564 12.974 0.536 2015

uruguay 0.638 7.177 0.009 2005-2006

Source: Preliminary estimates prepared for PAHO (PAHO 2017). Country level estimates may not yet be included in the global database on financial protection assem-bled by WHO and the World Bank.

*: considering monetary expenditures including imputed rent

Table 1: Catastrophic Health Expenditure and Impoverishing Health Expendi-ture* (% of households). Preliminary data

12


According to Figures 7 and 8, the poorest households have a greater risk

of impoverishment, while wealthier households have a greater possibility

of facing financial catastrophe due to health events.

Figure 7: Distribution of catastrophic health expenditure in % (SDG indicator 3.8.2, 25% threshold) by household consumption/income quintiles, in 11 countries. Preliminary data

Q1 Q2 Q3 Q4 Q5 Average

Costa Rica2012-2013

Argentina2012-2013

Bolivia2014

Chile2012

Ecuador2011-1012

Guatemala2014

México2014

Nicaragua2014

Panamá2007-2008

Perú2015

Uruguay2005-2006

Source: Preliminary estimates prepared for PAHO (PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.

8

7

6

5

4

3

2

1

0


13

Figure 8: Distribution of impoverishment due to out-of-pocket health spending in % (USD1.90 poverty line) by household consumption/expenditure quintiles, in 11 countries. Preliminary data

Figure 9 also shows that rural households have a higher incidence of impoverishment

and the distribution of catastrophic health expenditures similar between rural and urban

households.

Figure 9: Impoverishing out-of-pocket heatlh expenditures (left) and catastrophic expenditure (SDG indicator 3.8.2, 25% threshold) (right) by area of residence in 7 countries* in % of households. Preliminary data

Q1 Q2 Q3 Q4 Q5 Average

Costa Rica2012-2013

Argentina2012-2013

Bolivia2014

Chile2012

Ecuador2011-1012

Guatemala2014

México2014

Nicaragua2014

Panamá2007-2008

Perú2015

Uruguay2005-2006

Source: Preliminary estimates prepared for PAHO ( PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.

6

5

4

3

2

1

0

Urban Rural Urban Rural

Source: Preliminary estimates prepared for PAHO ( PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.

3.5

3

2.5

2

1.5

1

0.5

0

12

10

8

6

4

2

0

Bo

livia

20

14

Co

sta

Ric

a 20

12-2

013

Ecu

ado

r 20

11-2

012

Gu

atem

ala

2014

Méx

ico

20

14

Nic

arag

ua

2014

Per

ú 2

015

Bo

livia

20

14

Co

sta

Ric

a 20

12-2

013

Ecu

ado

r 20

11-2

012

Gu

atem

ala

2014

Méx

ico

20

14

Nic

arag

ua

2014

Per

ú 2

015

14


In the case of Chile, there is a lower incidence in Santiago than in the Regions for both indicators. In

Ecuador, households in rural areas present a higher catastrophic expenditure incidence than those in

urban areas. In Guatemala, this is reversed and urban households have a higher incidence of catastroph-

ic spending.

Bolivia shows several exceptions. First, it is the only country where the poorest face a greater propor-

tion of catastrophic health expenditure and spending is impoverishing also for the non-poor, although

not at the level of Guatemala and Nicaragua. Households in rural areas are twice as likely to face cata-

strophic expenditures than those in urban areas.

In Costa Rica, households in urban areas show higher catastrophic spending, while in Uruguay and Mex-

ico, households in rural areas have a higher incidence of catastrophic health expenditures. For Mexico,

rural areas are the ones that incur catastrophic expenses the most, as in Nicaragua and Peru.

CONFERENCE PAPER3. DISCuSSIOn AnD CHAllengeS

15

3.1 Increasing public investment: a priority needHealth financing in the Region is far from meeting the objectives set by the countries

in 2014 when they adopted the strategy for universal health. In fact, as mentioned, only

a small group of countries have achieved a public expenditure in health of 6% of GDP

(Figure 10), and direct expenditure in the Region accounts for 33% of total health expen-

diture.

3. Discussion and Challenges

Figure 10: Public health expenditure as % GDP and out-of-pocket health expenditure as %THE in the Americas, 2014

Increase in per capita public expenditure has historically been moderate, with rela-

tively low elasticities in health expenditure with respect to economic growth (below 1

in many countries).

Even the peak public health expenditure of 2009 was due to the impact of the eco-

nomic crisis on the GDP of the countries of the Region and not to an absolute in-

crease in public expenditure. However, although the average GDP growth rate would

recover by 2010 and continue until 2014 (23), the particular situations in the Region

in response to the global crisis caused the decline in public health expenditure as a

percentage of GDP to continue in several countries, as seen in Figure 11.


70

60

50

40

30

20

10

0

ATG

ARGBAH BAR

BIZBOL

BRA

CAN

CHI

COL

COR

CUB

0 2 4 6 8 10 12

DOM

RDO

ECU

GRDGUT

GUY

HAI HON

JAM

MEX

NIC

PAN

PAR

PER

SKN

SLASVG

SUR

TRT

USA

URU

VEN

OOP expenditure as a % of total health expenditure

Public expenditure in health as a % of GDP

OECD

16


Figure 11. Trends in public health expenditure in the Americas, 1995–2014 (selected countries)

Several studies show that countercyclical government spending has been essential for

meeting long term economic and human development targets (17–21) and will surely be

today to meet the United Nations Sustainable Development Goals adopted in 2015 with

a 2030 horizon.


8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

2010

2011

2012

2013

2014

Argentina

Bahamas

Bolivia

Brazil

Chile

Colombia

Costa Rica

Ecuador

El Salvador

Guatemala

Jamaica

Mexico

Nicaragua

Panama

Peru

Latin America andthe Caribbean

Public expenditure in health as a percentage of GDP


17

3.2 More efficiency: necessary, but not enoughEfficiency in the organization of services implies the adoption of people- and communi-

ty-centered models of care and the delivery of quality services by strengthening the first

level of care and building integrated networks.

Resource allocation in a health system is efficient when it achieves an optimal combi-

nation of morbidity and mortality reduction and greater financial protection for house-

holds that permits equitable access to health services with given resources. In this case,

the efforts are designed to yield what society needs and expects in terms of health and

well-being—a task that involves both the State and society.

The degree of productive and technical efficiency achieved will depend on how the

health services are managed—or to put it another way, on obtaining the best response

capacity through better coordination and linkage between levels of care and care net-

works.

To enhance efficiency in the health system, resources need to be allocated towards gen-

erating those health goods and services that society values the most (allocative efficien-

cy) and in the least costly way, or using the least possible amount of resources (technical

efficiency). Dynamic efficiency, in turn, implies guaranteeing conditions and efficiency

levels over time through innovation in the health systems in the broadest sense of the

word (29).

Payment mechanisms must be aligned with system objectives. Thus, it is important to

note that territorial and population-based payment systems––keeping in mind morbidity

levels and combined with mixed-level payment mechanisms––are potentially effective

regulatory mechanisms for meeting these objectives (30, 31).

Aligning incentives with health system objectives to promote integrated care and com-

prehensive services, and putting emphasis on the first level of care are initiatives that

can boost the efficiency of the system as a whole. Studies coincide in recommending the

adoption of payment mechanisms with circumstantial margins of flexibility and empirical-

ly contrasted macro- and micro-allocation instruments. Territorial capitation and epi-

sode-based payment (also called bundled payment or case rates, as in diagnosis-related

groups) are two examples of tools that can boost the efficiency of expenditure (32).

There are known mechanisms for boosting efficiency in resource utilization, among them

protocols for reducing clinical variability, centralized drug procurement systems, eco-

nomic evaluation, and the evaluation of other aspects, such as safety and quality in the

introduction of new technologies, programs to boost workforce efficiency and productiv-

ity, and the strengthening of disease prevention and health promotion. In this context, the

measures with the greatest short-term impact are related to resource allocation mecha-

nisms, including those involving drug procurement.

From 2010 to 2015, several countries in the Region, among them Brazil, El Salvador, and

Ecuador, made progress in this regard, channeling most of the growth in expenditure to

the first level of care to broaden access to these services and improve their quality. For

cases like those of Chile, Mexico, Peru, and Uruguay, results based payment systems were

18


also established (33). The 2008 reform in Uruguay involved the expansion of coverage and

pooling of social security and State funds to finance services to the beneficiaries of FONASA,

the national health insurance program that currently covers more than 70% of the population.

The risk-adjusted capitation payment system used in this fund also considers four targeted

areas associated with preventive measures for pregnant women and older persons and the

allocation of human resources.

During this period, Peru launched a results-based payment system through a project imple-

mented at the more general level of results-based budgets. Chile, in turn, introduced targets

in the per capita transfer system in primary health care and is developing a hospital payment

system based on diagnosis-related groups, aspiring to be the first country in LAC to employ

this tool. Suriname currently uses a capitation system for first-level providers and payment per

day and bed in the hospital setting.

3.3 Improving financial protection through pooled fundingIncreasing financial protection requires greater public expenditure, adopting efficient interven-

tions primarily at the first level of care to boost response capacity and increase linkage among

service networks. Increasing financial protection will reduce inequity in access. However, the re-

placement of direct payments should be done gradually through collective prepayment mech-

anisms involving different sources of financing, such as contributions to social security, taxes,

and fiscal revenues. Thus, the main components of a financing system designed to guarantee

financial protection to the population are the elimination or minimization of direct payments by

households and the pooling of funds.

Pooled funds, in which the risk of disease and the need for health services are shared by a

group of people through collectively financed prepayment mechanisms, is therefore key to

financial protection. Sharing risk under any institutional arrangement implies the transfer of

resources or a subsidy from healthy people to patients, as well as from young people to older

people – basically, from people who are not using the health services at a particular moment to

those who are. Moreover, these arrangements need to be mandatory, as opposed to voluntary,

to advance in the direction of universal health.

Moreover, for this financing to be solidarity-based, there should also be a subsidy, grounded

in redistributive policies, from households with greater contributory capacity (the wealthiest)

to those with fewer resources (the poorest), whose contributions are limited but whose health

care needs tend to be greater.


19

The existence of numerous small and fragmented funds

hinders the cross subsidies mentioned above, since it

provides an incentive for risk selection: each fund will at-

tempt to capture people who are better off economically

and in better health (the less risky) and exclude those

with limited resources and more health problems (the

higher risks). Smaller funds are more vulnerable to spe-

cific risks, such as illnesses that require more expensive

treatment. Therefore, funds that cover a small number

of people tend not to be economically viable in the long

term (7).

Furthermore, when the members of a fund share similar

characteristics in terms of the social and environmental

determinants of health to which they are exposed, the

risk of health problems tends to be inefficiently diluted,

implying a higher cost per person to treat episodes of

illness than in funds that cover people with different

characteristics. This is a powerful reason for advising

against segmented funds for communities with limited

resources.

The existence of numerous funds with their respective

mechanisms for collecting and pooling resources and

contracting services compromises the efficiency of the

entire health system due to the administrative costs

that it entails, as well as the cumulative superimposed

transaction costs. Single large funds tend to be a more

efficient type of organization than competing funds, as

long as organizational and institutional incentives are

adequate (34). Economies of scale in the operation of

these funds can generally be expected––not only in the

collection and pooling of resources, but in the contract-

ing of services for large numbers of people.

In addition to increasing access to quality health ser-

vices, financial protection is an important tool for fight-

ing inequity and poverty, as it converges with policies for

development and the social and economic protection of

societies. In other words, it represents a specific contri-

bution from the health sector to human development

strategies.

$76

20


4. Conclusion

By instituting reforms, changes, or transformations grounded in the values

of health as a right, equity, and solidarity, PAHO’s Member States have com-

mitted to moving toward the elimination of direct payment or out-of-pocket

expenditure, the creation of the largest possible pooled funds, and more

efficient public financing as the way of promoting greater individual and

community access to comprehensive quality services in integrated health

systems, with strengthening of the first level of care.

Advances in general are oriented in the right direction but are slow and

are reflected in the slow increase in public spending and the consequent

slow decrease in out-of-pocket expenses. The efforts to expand the gov-

ernment’s role in financing health using public financing have been insuf-

ficient so far to replace direct payments at the point of service (including

cost-sharing in government funded and private insurance schemes) as

source of funding. In consequence, financial barriers to access are still in

place, and households continue bearing an important share of the financial

burden to access health services and remain at risk of falling into financial

catastrophe or impoverishment.

It is necessary to accelerate the speed of changes towards universal health,

so that financing is no longer a barrier and a factor of catastrophe and

impoverishment and allows access to quality health services, in an equitable

and timely manner.

CONFERENCE PAPERReFeRenCeS

21

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health financing and financial protection in the americas

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