Health systems reform, equity, universal health coverage, and other

challengesAdam Wagstaff

Development Research GroupThe World Bank

Are

health

syste

ms try

ing

to

ach

ieve th

ese th

ing

s?

Yes

N

o

Better health outcomes – for everyone, not just the better off

Protection against the financial consequences of ill health and injury

Doing both these things efficiently – money wasted in the health sector could be spent on schools, improving the environment, culture, etc.!

Creating jobs. But health systems should not destroy jobs, especially formal-sector ones

Fostering a vibrant private sector Increasing the role of the State Boosting economic growth Improving the balance of payments

Wh

at’s

un

ivers

al c

overa

ge

got to

do w

ith it?

Instru

ment sp

ecifi

ed

Instru

ment n

ot sp

ecifi

ed

Rights approach› By law everyone has the right to health

(care)› Use courts? You need a health system, and

resources! Health insurance approach

› x% of the population pays only y% of the cost at the point of use for z% of all possible services

› Does UHC mean x=y=z=100? Everyone should get the care they need (from a defined package) without experiencing financial hardship as a result› Focus is on ensuring people get the health care

they need, without suffering financially› It comes close to our health system objective› It doesn’t specify the instruments to be used,

though in practice, UHC reforms often employ UHC instruments!

How do UHC instruments fare in getting us to UHC goals?

UHC countries don’t always do better in: › Ensuring people in equal need get the same

irrespective of their ability-to-pay, or› Protecting people from catastrophic out-of-pocket

spending UHC reforms don’t always:

› Push us toward the UHC goal› Push us much toward it when they do – even after

UHC reforms, we’re typically a long way from being at our UHC goal!

Need to step back and think more broadly about the health system and our goals

PRO-RICH

PRO-POOR

Before and after Vietnam’s “health insurance for the poor” reform

The situation after Indonesia’s “health insurance for the poor” reform

Flashpoints in the ongoing debate

Providers

Insurer(s)/Purchaser(

s)/Payer (s)

Government fund(s)

Households/

Patients

Who should

pay what?

And how?

One fund? What

should it cover?

Passive payer? Or active purchaser? Exposed to risk?

Competition? Insurers?

How should providers be paid? What other tools to be used to promote quality, efficiency,

and equity?

Should public providers be autonomous? Over what? And compete with one another for

contracts? And against private providers?

Who should pay what? And how?

Taxes typically most progressive finance method

Social health insurance (SHI) being reconsidered:› In OECD, regressive; but also hurts

formal-sector employment Taxes being used to fund

“insurance” cover for the poor, and near-poor, and even entire non-formal sector

Desire to reduce out-of-pocket spending, but barriers to higher taxes – so some services may require out-of-pocket payments!

One fund? What should it cover?

Desire to merge funds:› Linking entitlements to contributions

creates (horizontal) inequities› Political economy is hard when

benefit packages are different! Benefits package a big issue

› Differences between de jure and de facto coverage. Implicit – and probably inequitable – rationing!

› Could rationing be made more explicit and fairer? Getting the “better off” to pay something

at the point of use, and everyone to pay something for some very costly interventions until GDP is “big enough”? But how to operationalize?

Purchaser-provider split popular, but debate about how to do it

“Coverage” expansion used as opportunity to move from directly-managed vertically integrated model to a purchaser-provider split

Debate about merits of contracting purchasing function to an insurer

And about merits of multiple competing insurers. Risk-selection rather than lowering admin. costs? Does competition raise costs?

A few countries have private insurers compete with one another for a contract to be the 3rd-payer for a specific geographic area for a specific time period

Where’s information on payer performance coming from? Who’s getting it?

Autonomous public providers? Competing? Against private providers?

Government facilities haven’t always been granted the autonomy that’s required under a purchaser-provider split. But is autonomy good?

Does competition work? Depends whether prices fixed so competition is on quality?

Shifting to demand-side subsidies and consequent downsizing of public sector hard politically

Who monitors provider performance?

No blueprint for a health system

Confusion over whether UHC is an instrument or a goal

UHC instruments get us only so far toward UHC goals

Need to think more broadly, especially about health system goals, including efficiency

Multiple flashpoints in health system reform debate

Some agreement emerging › e.g. on shift to general revenues,

defragmentation of schemes, non-reliance on budgets to pay providers

But plenty of disagreements too› e.g. competition among purchasers and

providers, role of private sector, autonomy of public providers

How should providers be paid? What other tools to be used?

Shift away from budgets to performance-related payments, e.g. DRGs, P4P. But concerns about gaming, fraud, and costliness of sophisticated payment systems

Increasing use of sophisticated IT systems that allow the 3rd-party payer to hold providers accountable for quality of care, e.g. Rajiv Aarogyasri and RSB in India

Performance league tables – “naming and shaming” – also being tried