Experiences on Design: Turkey, Mexico and Thailand Ke Xu, Annie Chu, Rochelle Eng, Marlon Sison World Health Organization Western Pacific Region : Four Tracks, One Goal Towards Universal Health Care Manila, February 3-4, 2015 1
Overview of health financing functions Equity, efficiency, and sustainability Revenue collection Pooling Contributions to be collected efficiently and according to capacity to pay Risk sharing between the healthy and the ill; cross-subsidy from the rich to the poor Purchasing Making the best use of available resources 2
UHC and the three dimensions The trade-off among the three dimensions The available funding will always be limited Choices have to be made; priorities have to be set 3
Benefit package design - things that need to be considered Public policy objectives and overall architecture of benefit package The decision points: Service, providers, costs, population, and exemption rules Criteria Institutional arrangement and process: Who sets the rules and who decides? What is the process? How often is the review? 4
Pooling of Prepaid Funds China Philippines Turkey Thailand Viet Nam Mongolia Mexico Across different servies Public health services populationbased individual-based Clinial services outpatient npatient budget M ixed Insurance 5
GENERAL COUNTRY INFORMATION 6
Country basic information (2012) Country Total population (millions) Population Aged >60 (% total) GDP per capita (current USD) THE per capita (current USD) THE% GDP GGHE % GDP OOP% THE Life expectancy at birth (years) Korea 49.0 17 22 590 1 703 7.5 4.1 36.1 81 Turkey 74.7 11 10 557 665 6 5 16.8 75 Mexico 117.1 9 10 057 618 6 5 44.1 76 China 1384.8 13 5 941 322 5.4 3.0 34.3 75 Thailand 66.8 14 5 474 215 3.9 3.0 13.0 75 Indonesia 246.9 8 3 557 108 3.0 1.2 45.3 71 Philippines 96.7 6 2 588 115 4.4 1.3 57.6 69 Viet Nam 90.8 9 1 560 102 6.6 2.8 48.8 76 Note: THE stands for Total Health Expenditure; GDP for Gross Domestic Product; OOP for Out-Of-Pocket Source: WHO Global Health Expenditure Database; OECD Health Statistics 7
Structure of Total Health Expenditure (2012) Thailand* Turkey Mexico Philippines 0 20 40 60 80 100 Out of pocket Gov't Line Ministries Social Security Funds Other private Source: WHO Global Health Expenditure Database 8
OOP payments and catastrophic health expenditures OOP payments as % of THE (2002-2012) Catastrophic payment headcount 70 60 Country Catastrophic headcount Year Source % 50 40 30 Thailand 0.2% 2009 HSES Turkey 0.4% 2008 HBS 20 10 Philippines 1.5% 2012 FIES 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Mexico* 2% 2010 NHIES Mexico Turkey Thailand Philippines *Based on 30% threshold Source: WHO Global Health Expenditure Database 9
Health systems and health financing context Mexico Thailand Turkey Insurance Schemes Social Security Private sector Civil Servant Social Protection System in Health (SPSS: Seguro Popular, underfive, catastrophic expenditures) Private insurance Social Security Civil Servant Private sector Universal Coverage Scheme (UCS) Private health insurance Social Security Sosyal Güvenlik Kurumu (SSK) Private health insurance Total Coverage 78.61% 86.7% (2012/2011) 98.3% (2013) 90-97% (2011) Service Delivery Public beds (2005): 66% Private beds (2005): 34% Public beds (2008): 79% Private (beds 2008): 21% Public beds (2010): 86% Private beds (2010): 14% Notes: Most recent data available. Source: OECD, ENSANUT, NCBI, WB 10
Health systems and health financing context (con t) Financing of Social Insurance Scheme Mexico (SPSS) Thailand (UCS) Turkey Revenue Collections General government revenues (federal (89%, state 11%) Member contributions based on income; poorest two deciles fully subsidized General Tax revenues (progressive) No member contribution Member contributions based on income; poor population fully subsidized* Provider payment mechanisms Outpatient/Inpatient: Capitation per person Per-case basis (expensive treatments, FPGC) Fee-for service (private sector, tertiary care) Outpatient: Capitation Inpatient: DRG capped budget (inpatient) Fixed fees Outpatient: Capitation P4P FFS (Specialists, clinical lab tests, diagnostic imaging) Inpatient: Case-based system *Poor defined as less than 1/3 minimum wage 11
BENEFIT PACKAGE DESIGN 12
Institutional setting and process Mexico (SPSS) Thailand (UCS) Turkey Review of interventions for benefit package Institutional Arrangements Technical Committee of the Fund CNPSS (National Commission for the Social Protection in Health) Consejo Salubridad General (CSG) Federal Commission for the Protection against Sanitary Risks (COFEPRIS, semi-autonomous) CENETEC (Centro National de Excelencia Technologica en Salud) National Health Security Board Health Intervention and Technology Assessment Programme (HITAP; notprofit, semi-autonomous) Expert stakeholder group (propose recommendations) Reimbursement Commission (SSI) Medical and Economic Evaluation Commission Stakeholders involved Limited stakeholder involvement Government, civil society, health personnel, academics, patients and private sector (no manufacturers) SSI, Ministry of Health, Ministry of Finance, service providers, pharmaceutical companies 13
Criteria and other considerations Mexico (SPSS) Thailand (UCS) Turkey Criteria Cost-effective analysis Cost utility analysis Social acceptance Epidemiological profile Uses HTA concept Value for money Budget Impact Population need (diseases causing catastrophic expenditure, demand estimates) Uses HTA concept Cost-minimization Cost-effectiveness HTA limited to pharmaceuticals Other considerations Equity Resource availability Financial protection Improve quality of care Equity Resource availability Public opinion survey Political environment Equity Resource availability Improve quality of care 14
Benefit package (services) Mexico (SPSS) Thailand (UCS) Turkey Services Detection, prevention, family care, emergency cases, general survey, hospitalization, essential medicines Inpatient, outpatient care, preventative care, health promotion, family planning, essential medicines Preventive, outpatient and inpatient, hospitalization, emergency cases, blood products, vaccines, essential medicines High-cost Services Neonatal intensive care, paediatric cancers, cervical cancer, breast cancer and HIV/AIDS, cataract surgery Renal therapy, HIV/AIDS, antiretroviral, cancer, dialysis In-vitro fertilization services; HIV/AIDS; Organ, tissue, and stem-cell transplantation; renal therapy; cancer; cardiovascular surgery How often? Rolling Basis Annual Annual 15
Benefit package (population, cost coverage) Mexico (SPSS) Thailand (UCS) Turkey (SSI) Target Population Poor and informal sector Poor and informal sector General population Co-payments No co-payment Co-payment of 30 Baht; poor is free 20% co-payments for medicines and medical devices; capped co-payments for procedures in private hospitals 16
Context Summary Appropriate to the countries socio-economic development and health system settings Benefit package include services, costs and exemptions Principles and criteria Cost effectiveness, burden of disease (population need) Budget constraint, equity, financial protection Political, balancing different interests. Process and institutional arrangement Participation, neutrality and transparency Monitoring and feed back for policy making 17
Implications to the Philippines Inclusion of multiple stakeholders with a participatory, transparent process Compensation level to public and private facilities Co-payment and balance billing Patient information and empowerment 18
Thank you! 19