From Primary Health care to Universal Health Coverage

From Primary Health care to Universal Health Coverage Barbara McPake Institute for International Health and Development, Queen Margaret University, Edinburgh

Julius Nyerere Arusha declaration 1967: Ujamaa, socialism and selfreliance Philosophy to focus on villagisation ; community participation, bringing health care to rural populations, appropriate technology for health care We must not again be temped by offers of big new hospitals with all the costs involved until at least every one of our citizens has a basic medical service readily available to him. (Nyerere quoted in Morley and Lovel, 1986)

Primary health care in China Roots back to 1930s pre-communist era Post 1948 rural China organised on basis of co-operatives: each paid a levy to fund basic health care for its members Early model of primary health care delivered through barefoot doctor system Barefoot doctors were secondary school graduates, given 6 months training at a local hospital Promoted basic hygiene, preventive health care, family planning and treated common illnesses www.qmu.ac.uk/iihd

Primary Health Care Alma Ata 1978 134 nations represented. Virtually all signed up to: Health for All by the Year 2000

7 elements of PHC: PHC includes at least Health education Promotion of food supply and nutrition Promotion of safe water and basic sanitation Maternal and child health care including family planning Immunisation Prevention and control of infectious and common diseases and injuries Essential drugs wwwm.qmu.ac.uk/iihd

Selective versus Comprehensive PHC After Alma Ata, Walsh and Warren (1979) 1 immediately respond to Alma Ata a heated debate about how to do PHC and what it really means: A selected list of cost-effective interventions Or a revolutionary new approach to locating authority over health in communities and households based on community participation, appropriate technology and democratisation 1 Walsh J A & Warren K S. Selective primary health care: an interim strategy for disease control in developing countries. N. Engl. J. Med. 301.967-74.

Explicit consensus in 1978 on the primary health care approach Ideological warfare on what it really means Implicit consensus on a public health system to deliver it Not much discussion until 1987 on the publicprivate mix of financing and provision

Is PHC still the answer?

Health expenditure per capita: $PPP, 2008 (WHOSIS) USA Malta France Iceland Greece Portugal Qatar Lithuania Botswana Bulgaria Turkey Maldives Mauritius Grenada Libya Ecuador Georgia Peru Moldova Tuvalu Viet Nam Vanuatu Uzbekistan Syria Ghana Sierra Leone Chad Papua New Guinea Benin Malawi Mozambique Eritrea 0 1000 2000 3000 4000 5000 6000 7000 8000

Health expenditure (as previous slide) compared to GDP per capita (IMF, 2010; international $) USA Malta France Iceland Greece Portugal Qatar Lithuania Botswana Bulgaria Turkey Maldives Mauritius Grenada Libya Ecuador Georgia Peru Moldova Tuvalu Viet Nam Vanuatu Uzbekistan Syria Ghana Sierra Leone Chad Papua New Guinea Benin Malawi Mozambique Eritrea Global GDP 2010 = US$51,067,937,268,701.1 Global population 2010 = 6,885,217,727 Average GDP/capita = $7,417 US health expend/capita = $8,233 (World Development Indicator data) 0 10000 20000 30000 40000 50000 60000 70000 80000 90000 100000

Universal health coverage: From Agenda for Reform to WHR 2010

Agenda for Reform Advocated for greater roles for out-of-pocket payments (user charges) and private sector provision and insurance This advocated in part as a strategy to support primary health care

Reallocating resources away from hospital care is not easy. It is physically impossible to turn a few large and costly hospitals into many small primary-level health care units or to turn a nation s highly trained doctors and nurses into less trained and less expensive primary health care workers.... It is the financing of expensive hospital care that needs change, not the existence of the care as such. Governments must find ways to charge those who are able to pay for the benefits of public provided curative care. (p18)

But interpreted as generalised prescription of privatisation and user fee introduction Waves of countries introduced and increased fees in late 1980s and 1990s Experience: negative demand effects measured in multiple contexts; argument that fees required to improve quality sustained in only a few projects Little revenue raised in relation to global funding level Revenues raised could be important at local level

The Bamako Initiative 1987- A plan for self-sustained primary health care in African villages Communities share in the financing of local health services by buying drugs above the wholesale purchase price and using the proceeds to maintain drug supplies and subsidize services This core element known as a revolving drug fund Benin, Rwanda, Guinea and Mali scaled up this initiative as the basis of their national rural primary health care strategy In other countries, it remained a project operating in a few localities Main critique has been affordability of charges for poor families

Experience of out of pocket payments Source: Poullier et al. (2002) Patterns of global health expenditures: results for 191 countries, EIP/HFS/FAR Discussion Paper No. 51, Geneva, World Health Organisation.

Source: Xu et al. (2007) Household catastrophic health expenditure: a multi-country analysis, Lancet, 362, 111-117

On the basis of mounting evidence of: Significant negative demand side effects of user charges Limited contribution to overall financing Limited success with scaling up community financing to support a national PHC system Associations of out of pocket payments with catastrophic health expenditure Wave of reforms from late 1990s that removed user fees and supported free health care Has support for demand side (fee removal) been matched by support for supply side?

5 country case study of fee removal: Ghana, Nepal, Sierra Leone, Zambia, Zimbabwe User fee removal will probably: Increase use of health services Remove staff bonuses that have been paid from revenues Reduce ability of facilities to restock basic medicines with their own resources So needs to: Be offset by budget increases that can fill these gaps Be accompanied by human resource policies that ensure there is capacity to meet increased demand Find ways of mimicking the incentives to encourage more demand that user fees present Case studies Demonstrated importance of the supply side balance Showed that attempts to enact supporting supply side measures were variable across the countries and had mixed success Source: McPake et al., 2011

www.qmu.ac.uk/iihd World Health Report, 2010

Case study 1: China

Health system post-1981 The commune system, rural co-operative medical system and barefoot doctor programme all ended in 1981 Coverage of RCMS dropped from 90% to 5% in 1984 In the economy, shift towards individual production in family units In the health system, there was an effective privatisation In public health units, health workers incomes were dependent on sale of services under system of regulated prices Strong perverse incentives health workers recommended lucrative interventions and failed to offer access to cheaper ones www.qmu.ac.uk/iihd

Current reforms 850 bn. Yuan (US$124bn) to public funding of a basic health system Diversified systems of insurance differentiate entitlements of urban employees, other urban residents and rural residents Direct investment in expanded public services managed directly within government Strengthening referral and supervision systems Major programme of experimentation in delivery systems and payment mechanisms to inform further reform www.qmu.ac.uk/iihd

Chinese health insurance schemes in 2010 Urban Employee Basic Medical Insurance Urban Resident Basic Medical Insurance New Cooperative Medical Scheme Target population Formal sector urban workers Children, students, elderly, unemployed and migrants Rural residents Financing Premium (Y) Govt. subsidy 1559 0 138 120 157 120 Benefits Inpatient reimbursement (%) Total reimbursement ceiling 68 Six times average wage 48 Six times disposable income of local residents 44 Six times income of local farmers Source: Yip et al. (2010) Early appraisal of China s huge and complex health-care reforms, Lancet, 379, 833-42

Early evaluation of the reforms Successful in achieving high levels of coverage through diversified systems of insurance: 835m enrollees; 90% population has coverage But premised on a narrow package of care limited coverage of inpatient care and significant copayments Major inefficiencies remain difficulties enforcing essential drugs list; hospitals remain dominant in the system Considerable problems of quality, and human resource shortages to be tackled in second wave of reform have to start with primary care www.qmu.ac.uk/iihd

www.qmu.ac.uk/iihd World Health Report, 2010

Case study 2: Ghana

Background to health financing and social health insurance in Ghana User fees abolished at independence, reintroduced in 1969 and increased in 1985 and again under cash and carry in 1992; by mid-1990s fees accounted for 70-80% of non-salary operating budgets Delivery exemption policy piloted 2003; extended nationwide 2004 in response to persisting high MMR and inequities in access to ANC and SBA 1990s: Mutual health organisations established: external funding; covered mainly high cost inpatient care NHIS promised by successful New Patriotic Party in 2000 elections objective of removing financial barriers to access Passed into law 2003; implementation began 2005

Main features of NHIS in Ghana (Witter and Garshong, 2009) Sources of funding: NHIL=2.5% VAT; payroll deductions (2.5%) formal sector employees; public subsidies; mandatory income based premia for informal workers District-based mutual health insurance schemes (DMHIS) developed out of MHOs each district to have one; manage informal sector involvement Membership mandatory; risk pooling across district schemes Exempt groups, but tightly defined Broad minimum package of care Accreditation of providers Reimbursement on a modified diagnosis related group b basis

Source: Witter and Garshong, 2009

Composition of enrolment Largest share of enrollees (about two thirds) are exempted from making contribution (pregnant women exempted in 2008, children of members are main groups; also indigent, elderly) Registrations among informal sector workers are quite low (16% of the eligible population in 2008) In 2009 30% of households were currently enrolled in the NHIS, 14% had previously been enrolled and 56% had never enrolled. Richer households were significantly more likely to enrol than poorer households, There was higher enrolment in rural (19%) than urban (11%) areas (may relate to history of MHOs), but urban members more likely to renew. Sources: Jehu-Appiah et al., 2011; Witter and Garshong, 2009

Evaluation in 2008 Increase in access and decrease in out-of-pocket expenditure for members but no improvement in use of maternal care Financial sustainability has been major issue end of 2008 about $34m owing to health facilities in part because new members are not paying premia and funding increases have not been commensurate Money follows infrastructure? A hospital with a laboratory can bill for more services than a health centre without one hence resources are skewed towards better endowed areas Reports of informal payments being levied perhaps because staff have experienced growth in workload without compensation Source: Witter and Garshong, 2009

? World Health Report, 2010 www.qmu.ac.uk/iihd

Case study 3: Thailand

Health insurance system in Thailand 3 systems of health insurance Civil service medical benefit scheme (est. 1980) Social Security scheme (est. 1990) Universal coverage scheme (completed 2002) Succeeded the Medical Welfare Scheme (1975-) Voluntary health card scheme (1983-) 30 baht scheme

=5% of population (20% population uninsured 1998): Antos, 2007

Efficiency measures incorporated into UC scheme Capitation payment method Primary care gatekeepers HiTAP evaluates components of the package of care on cost-effectiveness criteria Separation of purchaser and provider

Equity features of Thai system UC has increased progressivity of health financing system Fewer Thai households faced with catastrophic health expenditure

percent Percent distribution of net government health subsidies among different income quintiles in 2001 and 2003 A comparison of percent distribution of net government health subsidies among different income quintiles in 2001 and 2003 35 30 28 31 25 20 15 20 22 17 17 18 16 15 15 2001 2003 10 5 0 Q1 Q2 Q3 Q4 Q5 Income quintile Note: The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123 Source: International Health Policy Programme, Thailand, 2007)

Concerns about the Thai system Significant gaps in benefit coverage under UC Capitation rate paid may be too low and providers may under-provide care Some hospitals are accruing significant levels of debt BUT the total cost of the system is currently 3.5% of GDP might be considered space to resolve these problems

www.qmu.ac.uk/iihd World Health Report, 2010

Conclusions Reaching universal coverage is an ever more difficult task challenges world s richest economies; most difficult for LICs; case studies have been MICs (but look at Rwanda for a good LIC case study, though heavily donor subsidised) Universal coverage is not only about financial accessibility cannot be achieved without attending to the efficiency of the health system Focus on a cost-effective package of care Use payment mechanisms that structure incentives towards efficiency for both providers and users Concentrate on strengthening primary health care system Thai model accepts heterogenous system albeit with universal access to the basics may be needed response to highly heterogenous population No quick fixes