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Social Health Insurance for Universal Health Coverage
Technical Meeting 62nd Session of the WHO Regional Committee
for the Eastern Mediterranean5-8 OCTOBER 2015, Kuwait
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Health Financing Systems and Universal Health Coverage
• In 2005, Member States endorsed a Resolution that urges countries to develop their health financing systems to:
- Ensure that all people have access to needed services without the risk of financial hardship
• In 2015, Heads of States adopted 17 SDGs with Target 3.8 calling on countries to pursue:– Universal Health Coverage
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WHR 2010: Three Dimensions of Universal Health Coverage
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4World Health Organization
The Financing Function“Collection”
“Purchasing”“Pooling”
Moving towards Universal Health Coverage Requires Well-Functioning Health Financing Systems
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Out-of-Pocket Payments Undermine the Performance of Health Financing Systems
01020304050607080
Group 340–76%
Group 224–58%
Group 18–20%
Share of OOP in THE by Country Group, 2013
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GENERAL GOV’T REVENUE– Financed through budgetary allocation– Beveridge approach– Main source of funding in:
• Globally – UK, Australia, Finland, Italy, Greece, Sweden and others.
• In EMR – G1: GCC “nationals”; G2: Iraq, Libya; G3: Afghanistan, Pakistan
SOCIAL HEALTH INSURANCE– Financed through obligatory payroll taxes– Bismarck approach– Main source of funding in:
• Globally – Germany, Japan, France, South Korea, Turkey and others.
• In EMR – G2: I.R. of Iran, Tunisia, Morocco; G3: Djibouti
OTHER ARRANGEMENTS– Private Health Insurance – voluntary/for-profit– Community-Based Health Insurance – voluntary/not-for-profit– Medical Saving Accounts – obligatory with no pooling– Others
Prepayments Options for Countries to Consider
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General Government Revenue
Strengths– Pools risks for whole
population
– Relies on many different revenue sources – taxes, natural resources, others
– Single centralized governance system with potential for administrative efficiency and cost control
Limitations– Variations in funding and
budgetary allocations due to changing gov’t priorities
– Often disproportionately benefits the better off
– Potentially inefficient due to complex public sector rules and procedures
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Social Health Insurance
Strengths– Mandatory contributions
based on ability-to-pay
– Perceived as a ‘benefit’ tax with more ‘willingness to pay’
– Protects health financing from gov’t annual budgetary process
– Additional health revenue source
Limitations– Potential to exclude the poor and
vulnerable unless subsidized by gov’t
– Administrative cost can be high if fragmented
– Benefit packages do not often cover for promotive/preventive care
– Potential negative impact on employment because of increased cost of production
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GENERAL GOV’T REVENUE– Financed through budgetary allocation– Beveridge approach– Main source of funding in:
• Globally – UK, Australia, Finland, Italy, Greece, Sweden and others.
• In EMR – G1: GCC “nationals”; G2: Iraq, Libya; G3: Afghanistan, Pakistan
SOCIAL HEALTH INSURANCE– Financed through obligatory payroll taxes– Bismarck approach– Main source of funding in:
• Globally – Germany, Japan, France, South Korea, Turkey and others.
• In EMR – G2: I.R. of Iran, Tunisia, Morocco; G3: Djibouti
OTHER ARRANGEMENTS– Private Health Insurance – voluntary/for-profit– Community-Based Health Insurance – voluntary/not-for-profit– Medical Saving Accounts – obligatory with no pooling– Others
Prepayments Options for Countries to Consider
MIXED OPTION
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Social Health Insurance Evolution (“SHI for UHC”)
• Historically, SHI covered formal sector (primarily public but also private) through obligatory payroll taxes
• Today, SHI evolved into a prepayment arrangement that covers formal and informal sectors and is financed by a mix of obligatory contributions and government budgetary allocations
• Why?– In low- and middle-income countries: large informal sector
(poor and non-poor) and vulnerable populations, unemployment– In high-income countries: aging populations, “unemployment”
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“SHI for UHC” in EMRScheme 1 Scheme 4 Scheme 3 Scheme 4 Pop (%)
EGY HIO (52%) 52%
IRNIHIO – 4 Funds (60%)
SSO – 2 Funds (33%)
AFMSIO (3.5%) Others (3.5%) 100%
JOR CIP (41.2%) RMS (27.2%) JUHs (1.3%)Other prepayment (17.5%)
87.5%
MOR CNOPS (9.1%) CNSS (24.9%) RAMED (28%)
Other prepayment
(4-5%)66-67%
SUD NHIF (28.7%)
Police and Military (5.6%)
Other prepayment (0.6%)
34.9%
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“SHI for UHC”
Characterized by:
• Increased Social Solidarity
• (Quasi-) Independent Fund with Autonomy
• Entitlements because of your citizenship and not because of your job
• Split between Financing and Provision
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Driving:
• Equity and Fairness
• Strategic Purchasing and Enhanced Efficiency
• Protected Fund for Health
• Financial Sustainability
• Empowerment of the insured
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• Covering the near poor and non-poor informal sector – Need to identify options and pursue their implementation
• Limiting Fragmentation– Need to structurally/functionally merge HIOs and Schemes
within HIOs• Ensuring Autonomy and Accountability
– Need to enact necessary legislations and enforce the regulations
• Investing in Information Technology– Need to develop population databases and HMIS for purchasing
• Framing the Role of Private Sector– Need to identify who is covering what and from which provider
Key Policy Issues in Designing “SHI for UHC” in EMR
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Implementing “SHI for UHC”
• Governance – enact adequate laws and other legal provisions
• Membership Management – bring all population groups within the fold of SHI
• Fund Management – determine needed fund and set contributions to ensure sustainability
• Benefit Design – define benefit package and identify who pays for what
• Provider Management – accredit providers to ensure quality, and contract wit them using adequate payment mechanisms
• Information Management – establish HMIS, organize provider reporting and institutionalize monitoring
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Thank You!