health reform, health financing, and population health dominic s. haazen, sr. health specialist, the...
TRANSCRIPT
Health Reform, Health Financing, and Population Health
Dominic S. Haazen, Sr. Health Specialist, The World BankRiga, Latvia
Presentation Outline
Program of Action elements relevant to this discussionKey health reform interventions in the countries in transitionDevelopments in health financing and payment systemsRecent developments in HIV/AIDSImplications for population health
Program of Action – ICPD 1994universal access - primary health careuniversal access – comprehensive reproductive health services
including family planning
reductions in infant, child and maternal morbidity and mortalityincreased life expectancy
Accomplishments – ICPD+5 1999population concerns integrated into development strategies in many countriesmortality in most countries continued to fallbroad-based definition of reproductive health increasingly accepted steps being taken to provide comprehensive services in many countries
increasing emphasis on quality of care
rising use of family planning methods greater accessibility to family planning
Unfinished Agenda – ICPD+5 1999Still unacceptably high mortality/morbidity
HIV/AIDS Infectious diseases, such as tuberculosisMaternal mortality/morbidityAdult NCD mortality for countries with economies in transition , especially among men
Adolescents particularly vulnerable to reproductive and sexual risks. Lack of access by many to reproductive health information and services
Constraints/Needs – ICPD+5 1999financial, institutional, HR constraintsgreater political commitment needednational capacity must be developed, but increased international assistance is needed more domestic resources must be allocated effective priority-setting within each national context is an critical factorintegrated approach: policy design, planning, service delivery, research and monitoring
Action Items – ICPD+5 1999ensure social safety nets are implementedstrengthen specific health programs:
infant/child health programs that improve prenatal care and nutrition,maternal health services, quality family-planning services efforts to prevent transmission of HIV/AIDS and other sexually transmitted diseases;
Action Items – ICPD+5 1999strengthen health-care systems to respond to priority demands
ensure resources are focused on the health needs of people in poverty
develop special policies and health promotion programs to address rising or stagnating mortality levelsstrengthen national information systems to produce reliable statistics in a timely manner.
Key Health Reforms – ECA RegionIntroduction of primary health careDecentralization of health facilitiesHealth insurance (various models)Provider payment reformsRationalization of health services
Hospitals, EMS, PHC, specialists
Introduction of health promotion and prevention approaches, strategiesAdoption of DOTS
WB Supported Interventions – 1991-2001% of Total Loans/ Credits
0%
5%
10%
15%
20%
25%
Primary Health Care
Hospitals
TB and AI DS
HMI S
Health
Promotion/ Disease
ControlHealth Policy Reform
Health Financing
Reform/ I nsurance
Quality I mprovement
Human Resource Dev.
Pharmaceutical Policy
Health Financing Dimensions
Revenue raising – amount/methodPooling of fundsResource allocationCoverage/benefit package
Out of pocket payments
Purchasing methods
Provision of services
Purchasing of services
Pooling of funds
Collection of funds
Allocation mechanisms(provider payment)
Allocation mechanisms
Allocation mechanisms
Ind
ivid
ua
ls
Contributions
Coverage
Coverage
Health care
Choice?
Choice?
User charges
Funding flowsBenefit flows
Health System Financing & Population Links
Revenue Raising Methodspayroll tax emerged as a standard source of health care financing14 countries have payroll taxes: 9 as main financing mechanism, 5 as complementarycontribution rates range from 2% in Kyrgzstan to 18% in Croatia7 countries rely primarily on taxationOut-of-pocket costs range from less than 20% in Slovenia and Croatia to over 80% in Georgia and Azerbaijan
0% 20% 40% 60% 80% 100%
Georgia
Azer.
Kyrgyz
Moldova
Kazakh.
Albania
Romania
Poland
Russia
Latvia
Slovakia
Hungary
Croatia
Estonia
Slovenia
Czech
Public OOP
Out of Pocket Payments in ECA
Out of Pocket Payments - ImpactOOP payments affect treatment choice
riskier interventions such as surgery require larger paymentsServices that may be seen as discretionary (pre- and post-natal care), may be avoided
Quality of care and waiting times may depend on ability to payUndermines universality of publicly financed health programs
0
2,000
4,000
6,000
8,000
10,000
12,000
CI S-7 Other CI S South-East
Europe
Turkey Russian
Federation
EU
Accession
Europe &
Central Asia
0
5
10
15
20
25
30
35
GDP/ Capita ($PPP)
Taxes/ Capita ($PPP)
Taxes % GDP
Revenue Raising Capacity …
0
100
200
300
400
500
600
700
800
CI S-7 Other CI S South-East
Europe
Turkey Russian
Federation
EU
Accession
Europe &
Central Asia
0
1
2
3
4
5
6Public Health/ Capita ($PPP)
Total Health/ Capita ($PPP)
Public Health as % GDP
… and Impact on Health Spending
Public Health Spending vs. GDPR2 = 0.9023
0
200
400
600
800
1,000
1,200
0 5,000 10,000 15,000 20,000
GDP/Capita ($PPP)
R2 = 0.9609
0
200
400
600
800
1,000
1,200
0 2,000 4,000 6,000 8,000
Tax Revenue/Capita ($PPP)
Coverage – “Basket of Services”Many/most countries have attempted to define, but with limited success
14 studies funded through WB alone
e.g., Armenia - universal coverage only for primary/emergency services; some secondary services available only for the poorEven when defined, non-poor often benefit disproportionately
Definition of “emergency” in Armenia
Urban-rural disparities in access
Payment Methods – Physician ServicesW. Europe All Hospita
lO/P
SpecialistPHC
Salary Finland Portugal
England Ireland
Italy Denmar
k German
y
EnglandIreland
Italy
Sweden
Fee-for-service France Belgium
Germany Sweden
Germany
Capitation England Ireland
Capitation/FFS Denmark
Italy
Capitation/Salary
Spain
Flat Rate/FFS Austria
Payment Methods – Physician ServicesECA Region All Hospital O/P
Specialist
PHC
Salary MD, BY, TM, TJ,
AZ
SI, AL, CZ, AM, RO, BG
SI, AL
Fee-for-service GE, LV LV, LT, PL, RO, BG
FFS/Volume limit CZ
Capitation AL, PL, HU
Capitation/FFS GE CZ, RO, BG, EE, SI,
SK
Capitation/Bonus GE, EE, LT
Capitation/Fund-holding
LV
Payment Methods – Inpatient Care
0
2
4
6
8
10
12
14
Western Europe ECA (existing) ECA (in Dev't)
Num
ber
of
Cou
ntri
es
Line I tem
Per Diem
Per Case
Global Budget
Global Budgetwith DRG/ Case-Mix Adjuster
Payment Methods and IncentivesMechanisms Incentives for Provider Behavior
Prevention Service Delivery
Cost Containment
Line Item Budget
Fee-for-Service
Per Diem
Per Case (e.g., DRG)
Global Budget
Capitation
Provider Payment Methods - Impact
Any one method by itself does not satisfy all objectivesAdditional incentives are needed to address those inherent in selected approachMore sophisticated methods often require information systems that may not (yet) be available in transition countries
0
200
400
600
800
1000
1994 1995 1996 1997 1998 1999 2000 2001 2002
Year of report
UkraineLatvia
Belarus
Russian Federation
Estonia
Casesper million
HIV infections newly diagnosed per million population1994-2002, selected countries, eastern Europe
EuroHIV
Lithuania
Up d
ate
at
3 0 J
une
20
0 3
0
20
40
60
80
100
1994 1995 1996 1997 1998 1999 2000 2001 2002
Year of report
Kazakhstan
Belarus
Uzbekistan
Casesper million
HIV infections newly diagnosed per million population1994-2002, selected countries, eastern Europe
EuroHIV
Moldova
Kyrgyzstan
Up d
ate
at
3 0 J
une
20
0 3 GeorgiaAzerbaijanArmenia
Tajikistan
Poland
Czech Republic
HungarySlovenia
Romania
HIV infections newly diagnosed per million population1994-2002, selected countries, central Europe
0
10
20
30
40
1994 1995 1996 1997 1998 1999 2000 2001 2002
Year of report
Casesper million
Serbia & Montenegro
EuroHIV
Slovakia
Upd
ate
at
3 0 J
une
20
0 3
HIV/AIDS Regional Support StrategyRaising political and social commitmentGenerating/using essential information
Estimating the economic and social impactImproving surveillanceMaximizing value for moneyEstimating resource requirements
Prevention of TB and HIV/AIDSHarm reduction, focus: CSW, IDU, prisons
Sustainable, high quality careFacilitating large-scale implementation
Implications for Population HealthUnfinished rationalization agenda:
Misallocation of resourcesService quality (incl. reproductive health)Under-funding of PHC and prevention
Limited public funding in many countries
Reproductive health must competeChallenge to ensure access for poor/rural
Provider payment systems incentivesMust encourage RH related activities
Implications for Population HealthPrimary health care “immature”
Obs./Gyn. specialists still do most RHPublic confidence in PHC abilities
Information systems tell us little about what is going on (“known unknowns”?)
Amount of ante-natal/post-natal careOther reproductive health activitiesHospitalization (ALOS, C-section, comp.)Disease surveillance
Thank you!!
Dominic S. Haazen, Sr. Health Specialist, The World BankRiga, [email protected]