Health financing policy: performance and response to economic crisis

Transcription

1 Division of Health Systems & Public Health Health financing policy: performance and response to economic crisis Tamás Evetovits Head of Office a.i., Senior Health Financing Specialist WHO Barcelona Office for Health Systems Strengthening Health financing and efficiency gains workshop Slovenia, 3 November 2015

2 Accounting for public spending on health Gov t health spending GDP = Total gov t spending GDP X Gov t health spending Total gov t spending Government health spending as share of the economy Fiscal context Public policy priorities

3 Public spending on health is above EU trendline, but below highest spenders R² = 0,65 Public spending on health as % GDP SLO GDP per capita (current PPP)

4 Public expenditure on health is not the driver of high public debt

5 Public expenditure on health is not the driver of high public debt in Slovenia Health as a share of total government expenditure, 2012 Cyprus Latvia Hungary Poland Greece Bulgaria Estonia Finland Lithuania Romania Croatia Malta Portugal Luxembourg Slovenia Spain Italy Ireland Czech Republic Slovakia Belgium Sweden France Denmark United Kingdom Austria Germany Netherlands GHED

6 Health financing within the overall health system Intermediate goals Health system goals Resource generation Revenue collection Equity in utilization Health gain Equity in health Governance Pooling Benefits Efficiency Quality Financial protection and equity in finance Purchasing Transparency & accountability Responsiveness Service delivery

7 Universal health coverage (UHC) Universal coverage is the hallmark of a government s commitment, its duty, to take care of its citizens, all of its citizens. [It] is the ultimate expression of fairness Dr Margaret Chan, Director General of WHO, at the 55 th World Health Assembly All people should get access to needed health services of sufficient quality to be effective (incl. prevention, promotion, treatment, prescription medicine, rehabilitation and palliative care) without the risk of being exposed to financial hardship

8 Two key measures for UHC UNMET NEED Financial protection against the cost of ill health

9 Slovenia is a top performer in UHC Unmet need for a medical examination for financial or other reasons by income groups in the European Union, EU-SILC data for 2012

10 Financial protection is excellent Out-of-pocket payments (OOPs) below 15% Netherlands Monaco France UK Luxembourg Slovenia Germany San Marino Denmark Norway Croatia Czech Republic Ireland Austria Sweden Andorra Iceland Estonia Finland Belgium Italy Spain Poland Slovakia Israel Hungary Switzerland Lithuania Greece Portugal Malta Russian Federation Latvia Bulgaria Cyprus Turkey Belarus Romania Bosnia and Herzegovina TFYRM Montenegro Turkmenistan Serbia Kazakhstan Albania Azerbaijan Kyrgyzstan Ukraine Uzbekistan Republic of Moldova Armenia Georgia Tajikistan OOPs as a share (%) of total expenditure on health by income country groups (high, upper-middle, lower-middle and low) Alarming zone Source: WHO Global Health Expenditure Database for 2011 Note: Data for Netherlands underestimates the true level of OOPs

11 A number to remember: keep OOPs low 15%

12 The share of public expenditure in total health spending in Slovenia is lower than in many comparable countries % of all health expenditure EE CZ HR NL EU15 EU13 WHO/Europe SIovenia 75 DE AT FI 70 SK IE HU WHO Europe: European Health for All database

13 While public spending is slightly below EU average, CHI coverage of co-payments helps to keep OOPs below 15%. Composition of health financing according to financing agents, 2012* % of current expenditure General Government Social Security Private out-of-pocket Private insurance Other * Or nearest year

14 More public spending means lower burden on patients. More public spending and better health policies Source: WHO estimates for 2012, selected countries with population > 600,000

15 More private/voluntary insurance does not mean lower OOPs except for a few CYP OOPs % total health spending BUL LAT LIT MTA POL ROM ITA EST FIN SWE CZE DEN GRE HUN LUX UK POR BEL AUT NET SPA GER IRE SLO FRA PHI % total health spending Source: WHO NHA data for 2012

16 Health financing policy objectives and performance in Slovenia Financial protection Does use of health services lead to financial hardship? Equity in financing Who bears the financial burden of paying for health services?

17 CHI is better than direct OOPs at the point of service use, but there would be no need for CHI if co-payments were reduced Co-payments are inefficient & most inequitable

18 Changes to benefits packages in EU in response to the crisis good and bad Number of EU countries Added new benefits Expanded population entitlement Reduced co-payments (or improved protection) HTA-based reduction in benefits Restricted population entitlement Ad hoc reduction in benefits Increased co-payments Source: Thomson et al 2015

19 The impact of the crisis Public spending on health was badly affected in several countries Efficiency gains were important but not enough to bridge a large or sustained spending gap Change (%) in public spending on health per person, : countries in which 2013 levels were lower than 2008 levels Protective action was not prioritised in economic adjustment programmes Source: WHO data

20 Sustained cuts in public expenditure on health in Slovenia: potential risk to UHC Also inefficiency of shifting more to CHI Millions of EUR In-patient curative and rehabilitative care Day cases of curative and rehabilitative care Out-patient curative and rehabilitative care Services of curative home and rehabilitative home care Services of long-term nursing care Ancillary services to health care Medical goods dispensed to out-patients Prevention and public health services Health administration and health insurance Capital formation of health care provider institutions

21 Change in share of total health financing of different sources in Slovenia, ,0 2,0 1,0 0,0 Public expenditure Central government Local government Social security funds Private expenditure Private health insurance Households Corporations -1,0-2,0-3,0 % Change

22 Public spending on health fell disproportionately in many countries including Slovenia Change in the health share (%) of total government spending, Pro-cyclical public spending on health Countercyclical public spending on health -30 Armenia Latvia Ireland Azerbaijan Montenegro Kyrgyzstan Turkmenistan Luxembourg Iceland Croatia Portugal Greece Ukraine Slovenia Spain fyr Macedonia Denmark Slovakia Norway Lithuania Finland Malta Russian Federation France San Marino Andorra Romania Hungary Serbia Netherlands United Kingdom Italy Belgium Germany Israel Poland Turkey Austria Sweden Estonia Czech Republic Cyprus Albania Bulgaria Switzerland Republic of Moldova Uzbekistan Bosnia Herzegovina Monaco Georgia Kazakhstan Belarus Tajikistan Source: WHO NHA database, 2013

23 Cyclical spending is not about taxfinanced NHS vs earmarked SHI Change in the health share (%) of total government spending, Pro-cyclical public spending on health Countercyclical public spending on health -30 Armenia Latvia Ireland Azerbaijan Montenegro Kyrgyzstan Turkmenistan Luxembourg Iceland Croatia Portugal Greece Ukraine Slovenia Spain fyr Macedonia Denmark Slovakia Norway Lithuania Finland Malta Russian Federation France San Marino Andorra Romania Hungary Serbia Netherlands United Kingdom Italy Belgium Germany Israel Poland Turkey Austria Sweden Estonia Czech Republic Cyprus Albania Bulgaria Switzerland Republic of Moldova Uzbekistan Bosnia Herzegovina Monaco Georgia Kazakhstan Belarus Tajikistan Source: WHO NHA database, 2013

24 Beveridge and Bismarck are not helpful Tax-financing: unpredictable annual allocation decisions make stakeholders argue for earmarking SHI: exclusive reliance on earmarked payroll tax is unsustainable in the long run Balanced revenue mix of payroll tax and budget transfers with counter-cyclical mechanisms pooled in a single fund

25 In most other countries with social insurance systems, tax revenues contribute a sizeable amount which can compensate for labour market fluctuation Netherlands 1 Denmark United Kingdom Czech Republic Luxembourg Sweden Romania Estonia Croatia France Italy Germany Austria Belgium Finland EU28 Slovak Republic Slovenia Spain Poland Greece Ireland Lithuania Malta Latvia Portugal Hungary Bulgaria Cyprus Social security funds Central and local government

26 Health financing policy objectives and performance in Slovenia Adequate funding levels Stable revenue flows Administrative efficiency

27 Is the Slovenian health system efficient? Do you get value for money?

28 Amenable mortality is low relative to the level of total per capita health spending 7000 Men Women LU LU Per capita total health expenditure (international PPP) ND AT DK DE BE FR SE IE FI IT UK ES PT MT SI CY EL CZ PO HR SK HU EE LT BG LV RO ND AT DEDK BE FR SE IE FI IT UK ES PT SI MT CY EL CZ POHR EE SK HU LT LV BG RO Male amenable mortality Female amenable mortality Source: GHED and WHO Mortality database

29 Premature mortality in Slovenia is decreasing faster than average age-standardized death rate - all causes, 0-64, per EE EU15 EU13 WHO/Europe SI IE HR CZ SK NL AT HU FI DE WHO Europe: European Health for All database

30 And life expectancy has increased rapidly since the 1990s EU15 Slovenia Closing the gap with EU15!

31 Infant mortality rates are consistently among the best very sensitive to health system performance Infant deaths per 1000 live births EU15 EU13 WHO/Europe SI AT 5 IE SK FI NL EE HU HR DE CZ WHO Europe: European Health for All database

32 Mortality due to diseases of the circulatory system have been effectively reduced in Slovenia age-standardized death rate number of deaths per EU15 EU13 WHO/Europe SI 500 HU SK AT EE HR CZ 200 FI IE DE NL WHO Europe: European Health for All database

33 But inequalities between east and west Mortality due to circulatory system diseases Source: National Institute of Public Health

34 Cancer mortality is high 290 age-standardized death rate number of deaths per HU EU15 EU13 WHO/Europe SI 230 CZ 210 HR AT EE IE NL SK 150 DE FI WHO Europe: European Health for All database

35 Some efficiency indicators of health service delivery already show good performance Average length of stay in hospital number of days 18 EU15 EU13 WHO/Europe SI 14 NL HR FI 10 SK HU CZ DE AT EE IE WHO Europe: European Health for All database

36 But potential efficiency gains: low occupancy while in-patient care admissions could be further reduced 30 In-patient care admissions per DE AT EU15 EU13 WHO/Europe SI EE CZ FI HU SK HR IE NL WHO Europe: European Health for All database

37 Relatively low physician density and average number of nurses Physicians low Nurses high EU Physicians high Nurses high UK Slovenia Austria EU Physicians low Nurses low Physicians high Nurses low

38 Rapidly rising percentage of 65+ population in Slovenia. % of population aged 65+ years DE EU15 EU13 WHO/Europe SI 16 FI NL AT 14 HU EE CZ HR SK IE WHO Europe: European Health for All database

39 ...not just older but overweight population: critical challenges for the health system

40 Summary Overall good performance of the health system. Good value for the resources spent Health financing system performs well for UHC but equity could be improved by reducing co-payments and less reliance on CHI Sustainability of the health financing system is at risk over-reliance on SHI contributions of an ageing population Increase efficiency by improving the purchasing function and service delivery