Phusit PrakongsaiKanitta Bundhamcharoen

Kanjana TisayatikomViroj Tangcharoensathien

International Health Policy Program (IHPP)

Presentation to IHPP Journal Club IHPP meeting room, Ministry of Public Health, Thailand

January 8, 2009

Regional case studiesFinancing health promotion in South-East Asia:

Does it match with current and future challenges?

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Outline of presentation

1. Background and objectives of the case study2. Burden of non-communicable diseases (NCD)

and risk factors 3. Financing health care and health promotion 4. Innovative financing for health promotion 5. Stakeholder views on financing health

promotion 6. Conclusions and policy recommendations

Background (1)Increasing burden of NCD and risk factors

Source: WHO (2006) Preventing chronic diseases: a vital investment

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Background (2)• Evidence indicates very low investment in

health promotion and disease prevention in South-East Asia region

• The 59th session of WHO-SEAR regional committee meeting in Dhaka, 2006– Request member states to adopt alternative,

innovative and sustainable sources of financing HP activities,

– Request RD to facilitate the establishment of innovative financing mechanisms

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Innovative financing HP in five selected countries (1)

• India: – The National Rural Health Mission is funded by

10% of tobacco tax of the central government– MOH plans to get at least 1-2% tax from tobacco to

finance tobacco control-related activities

• Nepal: – introduction of ‘cigarette tax’ in 1993 – one pisa

per stick of cigarettes (then increased to two pisa)– 75% of the fund to BPK Cancer hospital, and 25%

to other similar establishments

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Innovative financing HP in five selected countries (2)

• Sri Lanka:– has comprehensive tobacco and alcohol legislation with

taxation policy,– Establishment of the National Tobacco and Alcohol

authority funded by the central revenue

• Thailand:– Has comprehensive tobacco and alcohol legislation – Establishment of Thai Health Promotion Foundation,

funded by 2% of tobacco and alcohol excised taxes

• Indonesia:– No comprehensive tobacco or alcohol legislation– No national health accounts

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Objectives• To conduct case studies on the innovative and

sustainable financing mechanisms using information from national health accounts and other sources of information:

1. Reviewed the profile of non-communicable disease burden,

2. Examined current policy concerns among key

stakeholders on health promotion and financing health promotion,

3. Assessed current trend of financing sources of health promotion (public vs private) and spending profile,

4. Assessed the structure, function, and achievements of innovative financing HP.

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Methods• Literature reviews on

– Burden of disease, or extensive epidemiological situations of NCD

– Revenues generated for alcohol and tobacco, and laws related to taxation and tax rates

• Reviewed existing National Health Accounts (NHAs) about financing health care in general and HP in particular

• Conducted self-administered questionnaire survey to achieve key stakeholder views on innovative financing HP

• Reviewed innovative financing health promotion and country without such innovation, in-depth interviews of key stakeholders will be conducted.

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Research findings from this study

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DALY Profile of 11 member states of SEAR and the world

0 10 20 30 40 50 60 70 80 90 100

Sri Lanka

DPR Korea

Thailand

Indonesia

Maldives

WORLD

SEA region

India

Bangladesh

Myanmar

Nepal

Bhutan

Timor-Leste

Non-communicable Communicable Injury

Source: The World Health Report 2004

Country background indicators in five selected countries, HDI rank in 2007

Indicators Thailand Sri Lanka

Indonesia India Nepal

HDI rank 78 99 107 128 142

Population in 2015 (million)

66.8 20 251.6 1,302.5 32.8

GDP per capita US$ 2,750 1,196 1,302 736 272

Pop living below $1 a day (%)

<2 5.6 7.5 34.3 24.1

Health spending per capita, PPPUS$

293 163 118 91 71

Birth attended by skilled health personnel (%)

99 96 72 43 11

Physicians per 100,000 pop

37 55 13 60 21

Prevalence of selected risk factors in five selected countries

Risk factors Gender India Indonesia Nepal Sri Lanka Thailand

Alcohol consumption (litre per cap)

0.29 0.09 0.19 0.28 5.59

Smoking (%) Male 29.4 69.0 31.4 38.2 40.2

Female 2.5 3.0 2.0 2.4

Mean blood pressure (mmHg)

Male 124 123 124 123 119

Female 122 123 121 122 117

Physical inactivity (%)

Male 9.3 24.4 6.7 7.3 6.8

Female 15.2 17.8 9.7 13.8 11.8

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Total health expenditure as percentage of GDP 2000-2004

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Total health expenditure by financing sources in five selected countries in 2004

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Financing health promotion and innovative financing

• The Health Tax Fund of Nepal raised by earmarked tax of tobacco and alcohol consumption, is managed the BP Koirala Memorial Cancer Hospital,– Approximately 65-70% for Bhaktapur Cancer hospital,– the rest for National Health education, Bir Hospital,

Nepal Cancer Relief Society, etc.

• Revenue of Thai Health Promotion Foundation (THPF) collected from 2% earmarked additional tax from tobacco and alcohol consumption – In 2005, total expenditure was approximately 58 million

USD,– The mission is to empower civic society, raise social

awareness on major health risk behavior, promote well being of the citizens.

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The distribution of HP programs funded by THPF in 2005

The distribution of HP programs supported by ThaiHealth in 2005

34%

17%16%

16%

12%

5%

Tobacco & alcohol consumption control, road traffic injuries, etc.

Health promotion is specific population

Community capacity strengthening

Knowledge management in health promotion

Drug addiction, sexual behaviour, mental health, nutritional and environmental projects

Health promotion by health care infrastructure

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30.46

25.3622.47

19.47 18.94

05

1015

2025

3035

1991 1996 2001 2004 2006

Trend of prevalence (percent) of regular smokers among population aged more than 11 years from 1991 to 2006

Sources: Analyses from the Health and Welfare Survey, 1991-2006

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excised tax on tobacco and number of cigarette consumption from 1991 to 2006

Tax increase interventions and tobacco control

In Thailand

30 .525 .4 22 .5 19 .5 18 .9

55

79

0

10

20

30

40

50

60

70

80

90

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

year

perc

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0

500

1,000

1,500

2,000

2,500

3,000

Num

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f cig

arre

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cons

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(mill

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pack

s)

prevalence of cigarette smoking

percent of excised tax on tobacco

Number of cigarette consumption in million packs

Stakeholder views on financing health promotion (1)

Characteristics Indonesia Nepal Sri Lanka Thailand Total

No. of respondents

37 27 34 117 232

Male: female 62:38 84:16 74:26 77:21 75:25

Average age of respondents

NA 55.9 55.6 50.2

Professional backgroundMedical professionals

30% 28% 37% 18% 25%

Health related administrators

- 25% 17% 50% 32%

Public health 38% 16% 30% 25% 27%

Others 32% 31% 16% 7% 16%

Perception on financing health care and health promotion

Indonesia Nepal Sri Lanka

Thailand Total

Sufficiency of health care financeInadequate 86.5 93.8 78.3 82.1 83.6

Adequate 8.1 3.1 19.6 16.2 13.8

Don’t know 5.4 3.1 2.2 1.7 2.6

Government priority on HPHigh priority 8.1 18.8 15.2 24.8 19.4

Moderate 16.2 50.0 54.3 59.0 50.0

Low priority 75.7 31.3 30.4 14.5 29.7

Spending on health promotion in relation to burden from NCD

Indonesia Nepal Sri Lanka

Thailand Total

Sufficiency of financing HP in relation to NCDAbundant 0 0 0 0.9 0.4

Sufficient 13.5 0 4.3 15.4 10.8

Moderate 5.4 25.0 32.6 22.2 22.0

Insufficient 62.2 65.6 52.2 52.1 55.6

Severely insufficient

18.9 9.4 4.3 8.5 9.5

Don’t know 0 0 6.5 0.9 1.7

No. of respondent 37 32 46 117 232

How much should governments spend on health promotion?

Indonesia Nepal Sri Lanka

Thailand Total

Double of current level of spending

24.3 50.0 43.5 26.5 32.8

Triple 43.2 21.9 21.7 16.2 22.4

Quadruple 13.5 9.4 4.3 4.3 6.5

More than quadruple

18.9 3.1 6.5 9.4 9.5

Don’t know 0 9.4 19.6 11.1 10.8

missing 0 6.3 4.3 32.5 18.1

No. of respondent

37 32 46 117 232

Desirability of innovative financing for HPPotential sources of financing HP

Indonesia Nepal Sri Lanka

Thailand Overall

Earmarked tax from alcohol

3.86 4.53 3.95 4.51 4.30

Earmarked tax from tobacco

4.11 4.52 3.88 4.41 4.27

International donor

3.78 3.91 3.88 2.49 3.17

Domestic donor 3.89 3.13 3.27 2.73 3.08Earmarked tax from VAT

3.22 2.96 2.48 2.95 2.90

General tax 2.95 3.30 2.65 2.78 2.85Earmarked tax from SHI

2.68 3.75 NA 3.73 2.83

Earmarked from gasoline

3.03 2.50 1.75 2.66 2.52

Reallocation from other sectors

1.97 2.48 1.95 2.25 2.18

Feasibility of innovative financing for HPPotential

sources of financing HP

Indonesia Nepal Sri Lanka

Thailand Overall

Earmarked tax from alcohol

3.92 4.43 3.95 4.21 4.14

Earmarked tax from tobacco

4.08 4.34 3.93 4.21 4.15

International donor

3.81 3.67 3.77 2.09 2.92

Domestic donor 3.89 2.75 2.90 2.40 2.79Earmarked tax from VAT

3.22 3.04 2.83 2.39 2.70

General tax 2.86 3.12 2.76 2.59 2.74Earmarked tax from SHI

2.68 3.07 NA 3.07 2.40

Earmarked from gasoline

3.14 2.62 1.88 2.12 2.30

Reallocation from other sectors

2.03 2.11 1.83 1.62 1.79

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Opinions on key barriers to introducing innovative financing for HP

• Lacking of vision and commitment to improving population health among politicians and policy makers,

• Limitations of financial and human resources for HP and disease prevention,

• Bureaucratic system and poor management of the government,

• Poverty and lack of community participation,

• Lacking of knowledge and inadequate information on the magnitude of NCD and its impact on public health.

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Conclusions• Current level and profile of spending on health

promotion and disease prevention does not match huge disease burden from NCD,

• Among these five countries, Thailand paves advanced step towards innovative financing health promotion, – Nepal had an opportunity to reorient towards primary

prevention rather than focusing on hospital-based cancer treatment,

– Sri Lanka, the introduction of tobacco and alcohol tax could be a potential source,

– The introduction of social health insurance in Indonesia provides an opportunity to ensure that disease prevention and health promotion services are included in the benefit package of SHI.

• Disease Control Priorities in Developing Countries 2006 (second ed) – DCP2

• Comprehensive literature reviews on cost-effectiveness interventions ใน 4 four groups:

– Infectious disease, reproductive health, and under-nutrition

– Non-communicable disease and injury,

– Risk factors,– Consequences of disease and injury

• It also provides recommendations on health system strengthening, and effective management for high priorities of disease prevention and health promotion. http://www.dcp2.org/pubs/

DCP

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Policy recommendations from the case study

• Mobilize more resources through increased public investment for health promotion,

• explore potential feasibility to establish innovative financing for health promotion through introducing earmarked tax from tobacco and alcohol,

• Ensure that public health insurance schemes cover health promotion in their benefit packages,

• Well prepare good evidence when the window of opportunity is opened,

• Increase value of money, namely efficiency gained through existing spending on health promotion and reorient programs towards primary prevention focus.

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Policy recommendations from the regional consultation in Jakarta (1)

Member states

• Need to mobilize more resources through increased public investment for health promotion, with a need to reorient towards primary prevention and promotion focus.

• Have to explore potential feasibility to establish innovative financing for health promotion through:– general revenue;– introducing dedicated tax from tobacco and alcohol;– ensuring health insurance funds to cover the prevention

and health promotion in their benefit packages.

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Policy recommendations from the regional consultation in Jakarta (2)

WHO

• WHO, in collaboration with regional institutions, needs to develop a guide/methodology for collecting and analysis of information on financing HP,

• Should widely disseminate the experience of use of the dedicated tax and alternative financing,

• Provide technical support for capacity building for policy and program development.

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Thank you for your kind attention