Tim Evans

Senior Director, Health, Nutrition and Population, The World Bank Group

Ministerial Meeting on Universal Health Coverage: The Post-2015 Challenge

Singapore, 10-11 February 2015

Universal Health Coverage: Financing, Services, Results

Outline

• UHC is a central to development

• Financing

• Services

• Financing Services for Results

• Learning to do better

2

Pervasive Inequities in Maternal and Child Health Services Coverage

Source: World Health Report 2013

Millions more suffer financially when they use health services

- 30 60 90

WPRAMR

SEAEURAFR

EMRimpoverishmentcatastrophic

Number of people (million)

Over 100 million pushed into poverty annually from out of pocket expenditures on health care

World Bank New Goals

5

End Extreme

Poverty by 2030

Boost shared

prosperity (increase income of bottom 40%)

Financial Protection No one is kept in, or pushed into, poverty due

to out-of-pocket expenditures.

Service Coverage Everyone receives the quality health services they need

and is protected from public health risks.

Healthy Societies All societies invest in the structural foundations of good

health, e.g. water & sanitation, education, social protection, transport, gender, environment, etc.

Health Global

Practice

UHC is central to translating the WBG Development Goals

Universal Health Coverage by 2030

Financing

8

Beyond Bismarck and Beveridge

• Bismarck: 1883 – – multi-payer system of employer/employee-based

contributions, aka social health insurance.

• Beveridge: 1942 - – Tax financed, single payer, comprehensive

services, free at point of service

• Low levels of “formal employment” and “tax collection” in many LMICs require going beyond Bismarck and Beveridge financing

High levels of Informal employment/poverty characterize 21st century challenges for UHC

Country Informal employment (2010)

Population living on $2-a-day

Philippines 86% 43%

Indonesia 78% 53%

Vietnam 74% 46%

Thailand 65% 5%

Health Systems grow!

11

Strictly Confidential © 2014

Managing Money

• Pooling

• Purchasing

• Payment

• Principles

• Protection, Progressive, Priorities

• Politics –

• Pluralism and Polycentrism – • Private – Public

• Personal – Population

• Providers - Patients

• Preferred Practices – no single “best”

• Performance metrics

Services

13

– ↑ NCDs

– ↓ Dependency Ratios for Social Safety Nets

– ↑ Expectations

China

ThailandVietnam

Indonesia

Philippines

05

10

15

20

25

30

Sh

are

of to

tal p

opu

latio

n (

%)

1950 1970 1990 2010 2030 2050 2070Year

Source: UN

Population aged 65+, 1950-2070

14

Aging and Lifestyle Changes

16

Public Health Services are central to Universal Health Coverage

Financing Services for Results

18

Single Greatest Opportunity To Curb NCDs is Tobacco Taxation

50% rise in tobacco price from tax increases in China

prevents 20 million deaths + generates extra $20 billion/y in next 50 y

additional tax revenue would fall over time but would be higher than current levels even after 50 y

largest share of life-years gained is in bottom income quintile

Source: Global Health 2035: Lancet 2013.

20

Argentina’s Plan Nacer: Incentivzed Financing Scheme

NATIONAL

GOVERNMENT

PROVINCIAL

GOVERNMENTS

Health outcomes

Enrollment

Pay for performance

HEALTH

FACILITIES

Fee for

service

Umbrella Agreements

EXTERNAL AUDIT

Provincial

Health Insurance

Performance Agreements

EXTERNAL AUDIT

Health facility

decides on the

use of funds

Plan Nacer Reduces Neonatal Mortality

0.062

0.029

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

Control Beneficiaries

Neonatal Mortality of LBW Babies 0.0095

0.0025

0

0.001

0.002

0.003

0.004

0.005

0.006

0.007

0.008

0.009

0.01

Control Beneficiaries

Overall NeoNatal Mortality

Series1

Lessons from Argentina Plan Nacer

• Very effective

– More & better prenatal care

– Better birth outcomes & less neonatal mortality

– No negative effect on Non-Beneficary outcomes

• Innovative

– Incentives small in funding (2%)

– Leveraged other 98%

– Increased productivity

• MNCH model for MICs post 2015?

Source: Gertler et al. 2014

Immunization Coverage by Asset Quintile over time in Bangladesh (Source: Adams et al. Lancet 2013).

Source: BDHS data

Effective Coverage of MDG and NCD Interventions in Chile (Source J. Vega 2014)

96%

100%

99%

94%

82%

64%

92%

17%

35%

58%

56%

54%

Antenatal care (>=1 visit)

Skilled birth attendance

Family Planning

Pentavalent 3 immunization

TB treatment success

HIV-AIDS ART coverage

Improved Sanitation

High Blood Pressure

Diabetes

Depression

PAP smear

Mammography

MD

G d

ise

ase

sN

CD

18%

34%

56%

55%

52%

13%

42%

82%

61%

77%

High Blood Pressure

Diabetes

Depression

PAP smear

Mammography

NC

D

Public Private

Effective Coverage of Acute Respiratory Infections (ARIs) in 4 countries

512,392 560,120

973,840

364,950

112,337

28,967

164,549

55,632

Kenya Nigeria Uganda Tanzania

# childrenwith ARI

# childrenwhosoughtcare

# casescorrectlydiagnosed

Sources: UNPOP for Population data. SDI for provider competence estimates. DHS for prevalence and utilization data.

% of ARI cases correctly diagnosed and treated

21.9%

15.2%

16.9%

5.2%

21.9%

15.2%

16.9%

5.2%

OOP Spending Remains High in Many Countries Despite Financing Reforms

Indonesia

Mongolia

Philippines

Thailand

Cambodia

PNG

Lao PDR Malaysia

Vietnam

China

1030

5070

90

Sha

re o

f tot

al h

ealth

exp

end

iture

(%

)

250 1000 5000 25000 75000GDP per capita, US$

Source: WHO

OOP share of total health expenditure, 2011

OOP spending shares remain high in the region (Thailand is an exception).

27

Sub-national health impoverishment, Thailand 1996 to 2008

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

1996 1998 2000 2002

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

2004 2006 2007 2008

New Measures for UHC

29

Macro-economic impact of Thailand UCS: increased private consumption, Bhartia et al 2013

Increase private consumption followed increase in public health spending, when UHC launched in 2002

Learning to Do Better

30

Strictly Confidential © 2014

Argentina

Brazil

Chile

China

Colombia

Costa Rica

Ethiopia

Georgia

Ghana

Guatemala

India

Indonesia

Jamaica

Kenya

Kyrgyz Republic

Mexico

Nigeria

Peru

Philippines

South Africa

Thailand

Tunisia

Turkey

Vietnam

“Going Universal”: 24 country case studies

Japan-WBG Study on UHC: 11 country case studies

The JLN is a practitioner-to-practitioner learning network of 9 countries in Africa and Asia committed to accelerating progress of UHC reforms:

Ghana India Indonesia

Mali

Vietnam

Malaysia Kenya

Nigeria The Philippines

Toward Universal Health Coverage by 2030