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Dr. Anikara S. Atamunotoru July 24, 2018

Health Care Financing: Confronting Challenges in (Achieving) Universal Health Coverage and Service Delivery. Dr. Anikara S. Atamunotoru July 24, 2018. Outline. Background - Health Health System and Health System Building Blocks

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Dr. Anikara S. Atamunotoru July 24, 2018

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  1. Health Care Financing: Confronting Challenges in (Achieving) Universal Health Coverage and Service Delivery Dr. Anikara S. Atamunotoru July 24, 2018

  2. Outline • Background - Health • Health System and Health System Building Blocks • Health Care Financing within the context of the Health System and Health financing functions • Understanding Universal Health Coverage • Health Care Financing and Universal Health Coverage • Rivers State Diagnostic Survey Snap Short • Key Issues in HCF in the Context of UHC • Efforts to Address Challenges

  3. Health is a Right • Article 25 of the Universal Declaration of Human Rights 1948 recognizes Health as a right. • “It is a fundamental human right and … a most important world-wide social goal.” • WHO defines Health as: ‘a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity’.

  4. Health as a Right contd • In year 2000, the WHO ranked the health systems of its 191 member states in its World Health Report. • France, Italy and San Marino – Top 3 • UK – 18, USA – 31, Tunisia – 52, SA – 175. • Nigeria – 187 only above DRC, CAR, Myanmar and Sierra Leone. • About 17 years later, what has happened?? • Life expectancy – 47 in 2000; 55 (F), 54 (M) in 2016. • Maternal Mortality rate – 289/100,000 (99); 576/100,000 (2013) • Under 5 mortality rate – 201/1000 in 2003; 128/1000 in 2013 • Out of pocket expenditure – 61.6 % in 2000; 67% in 2015

  5. WHY ?? Myriad of reasons were thought to be responsible for this: - • Low public spending on health, • High levels of out of pocket spending • Inefficiency in health expenditures. • HRH challenges, Lack of equipment, Drugs, Access, Affordability, Dilapidated infrastructure etc. The way a country finances its health care system has implications for the performance of its health system

  6. What is a Health System?? • WHR 2000 refers to a health system as consisting of “all organizations, people and actions whose primary purpose is to promote, restore or maintain health”. “Good health allows children to learn and adults to earn” WHO • Underinvestment in health underlines the poor health statistics and the vulnerability of households to catastrophic health spending (due to limited financial protection)

  7. Health System Building Blocks (WHO)

  8. Interaction of Health System Building Blocks

  9. Health Care Financing within the Health System • WHO defines Health Financing as a “function of a health system concerned with the mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system”. • The purpose of health financing is “to make funding available, as well as to set the right financial incentives to providers to ensure that all individuals have access to effective public health and personal health care”

  10. Health Care Financing contd • All health financing approaches try to fulfill three basic principles of public finance:- 1) Resource Mobilization: mobilizing resources from variety of sources such as direct or indirect general taxation, earmarked taxation, and health insurance contributions, in order to provide individuals with the intended packages of health services. 2) Pooling and management of the mobilized resources to ensure that the risk of having to pay for health care is borne by all members of the pool. 3) Purchase of health services with the pooled funds including the variety of ways health care providers are paid to deliver specified set of interventions equitably and efficiently. .

  11. Health Financing contd Therefore, a good health financing system… • Raises adequate resources/funds for health • Ensures access to quality health care regardless of ability to pay • Protects people from catastrophic health expenditures • Allocates resources and purchases goods and services in ways that improve quality, equity, and efficiency • It provides incentives for providers and users to be efficient The use of public resources has a direct impact on the level of health service coverage and financial coverage (i.e. financial risk protection), as well as how equitably both are distributed – UHC!!

  12. What is Universal Health Coverage (UHC)? • UHC is a goal (aspirational) All people have access to effective and high-quality health services, without experiencing financial hardship: • Universal: All people regardless of ethnicity, gender, social status • Health services: health promotion, prevention, curative, rehabilitation, and palliative • Quality: sufficient quality to be effective • Financial hardship: low out of pocket costs and the risk of catastrophic health expenditure

  13. Dimensions of Coverage

  14. Measuring UHC: It is a challenge! • WHO and World Bank UHC Measurement Framework (2014) • Financial coverage • Households experiencing catastrophic health expenditure (%) • Households pushed below poverty line (%) • Health service coverage • Antenatal care (% pregnant women) • Skilled birth attendance (% pregnant women attended by skilled health personnel) • Immunization (% 1-year olds PENTA 3) • Populationcoverage with equity • Disaggregate population coverage by gender, wealth quintile, place of residence

  15. Target Indicators to Monitor Progress towards Achieving UHC

  16. SDGs and Universal Health Coverage Goal 3: Ensure healthy lives and promote wellbeing for all at all ages. Target 3.8: Achieve UHC (adopted in 2015)

  17. Other SDGs that support the achievement of UHC!

  18. Health Care Financing and UHC: WHR 2010 The WHR 2010 proposes three inter-related health financing strategic options for UHC: • Countries need to ensure adequate spending on health (raise sufficient funds): More Money for Health • Improve spending efficiency (reduce and eliminate inefficient use of resources): More Health for the Money • Reduce heavy reliance on direct OOP payments: More Equity for Health • SGDs adoption in 2015 reinforced this perspective - recognizing the need to explore the level of resources available for health systems, and the use to which they are put. (“Addis Ababa Action Agenda on Financing for Dev”)

  19. Key Health Spending Estimates/Benchmarks Estimates of how much should be spent on health! Policy Discuss!! • Government Spending per capita - • Target is $86 per capita – Nigeria spent $31 in 2013. (36%) • Budgetary allocation to the Health sector (Abuja Dec.) • Target is 15% - Nigeria allocated 4.6% in 2016. • % of GDP devoted to healthcare. • Benchmark of 5% - Nigeria spent 1% in 2013. • Household expenditure on Health as a % of Total Health Expenditure • Target is 30%, - In 2005, HHE as a % of THE was 67%. • Level of Financial risk protection • Target is 90%, - In Nigeria, < than 5% of the pop. is covered.

  20. Why do we need to spend more and spend well??

  21. Sources of Health Financing in Nigeria Source WHO Health Expenditure, 2013

  22. Financing Health in Nigeria Financing Health in Nigeria Share of THE by Financing Agents • Public spending – Government. • Household Expenditure -Out-of-pocket payments • Donor funding • Prepayment mechanisms (National, Social, Community and Private health insurance).

  23. Rivers State Diagnostic Survey Snap Short • Second largest economy in Nigeria after Lagos State • Economic activities dominated by crude oil & natural gas production, accounting for 83.3% of its GDP • Between 2011 and 2015, the state is the recipient of the largest allocation from the Federation Account • Statutory allocations in 2011 was N256.2 billion, but fell to N181 billion in 2015 • IGR grew at an average of 11.2% per year from N61.8 billion to N94.5 billion between 2011 and 2015 respectively • Rivers State is the second highest IGR contributor in the country but dropped for Ogun State in 2017 • Some health programmes such as HIV/AIDS, TB and malaria are primarily funded by donor sources

  24. Rivers State Survey contd • Risk of Catastrophic Health Expenditure - 50.3% • OOP spent at Chemists/PPMVs – 51.7% • Awareness of Insurance- 27.7% • Coverage by a pre-payment scheme – 1.7% • Willingness to Pay- 83.6% (Higher amongst rural residents)

  25. Key Issues 1 Revenue Generation • The predominant health financing mechanism in Nigeria is “Out of Pocket payment”. • Discourages poor people from seeking health services. • If they must, there is a risk of impoverishment. • Low level of Government funding for health at all levels. • Inefficient use of available resources. • Disproportionate funding – Recurrent/Capital, Primary/Tertiary health facilities etc.

  26. Key Issues 2 Pooling • Small, Fragmented pools of health insurance and other financial risk protection schemes. • The NHIS mainly covers Federal civil servants. Purchasing services • Passive purchasing – Payment for services not linked to any form of results. • Poor quality of services.

  27. Financing and Achieving UHC: What is Required? • Political Commitment: de jure and de facto • Financing: Public financing from general revenues (DRM), protection of the poor, SHIS • Service Delivery: PHCUOR, Improve efficiency in hospitals, maximize use of the private sector • Strategic purchasing: purchase results instead of just paying for in-puts • Public Financial Management and Transparency • Learn from other countries that have achieved UHC or have made great progress • Activate the BHCPF!!!

  28. Efforts to Address the challenges Past • Adoption of the Health for All by year 2000 • NHIS – 1999, Began implementation 2005. Ongoing • NHAct in 2014 – Basic Health Care Provision Fund. • Decentralization of NHIS. • More External funding – SOML (2015).

  29. NHAct in 2014 – Basic Health Care Provision Fund (BHCPF). National Health Act provision for health care financing – 1% CRF for BHCPF: • 50% of the BHCPF: provision of basic minimum package of health services to citizen in eligible “primary and secondary” facilities through NHIS platform; and • 20%:essential drugs , vaccines and consumables • 15%: maintenance of facilities, equipment and transport • 10%: developing human resources for health services • Through the NPHCDA platform • State Supported Health Insurance Program (SSHIP) Objective: To rapidly expand coverage towards UHC • Saving One Million Lives’ scheme launched in 2015 -to expand access to essential primary health care services for women and children. …

  30. UHC: All people have access to effective and high-quality health services, without experiencing financial hardship National Health Act & SSHIP support progress to achieve UHC • Universal •SSHIP objective • Health services •Minimum basic package • Quality - supply side •BHCPF: • 20% drugs • 15% maintenance • 10% training • Financial protection – demand side •BHCPF: • 50% for insurance provision

  31. Things to do differently • Mobilize more domestic resources for the health sector. • Use resources more efficiently. • Remove financial barriers to access • Shift focus from Out of Pocket payments . • Deepen pre-payment and risk pooling coverage penetration USAID-Health Finance and Governance is working with Government at all levels to tackle these challenges– Do your part!!!

  32. Take Away Message! • Health is a fundamental human Right as declared by the UN. • For good health the 6 building blocks interact to deliver services that “allows children to LEARN and adults to EARN” • That HCF permeates the other building blocks of the health system for improved health. • The basic functions of HCF are: revenue collection, risk pooling and purchase of health services. • It is important to have HCF reforms to enable the health system “Spend More Spend Well” to achieve UHC

  33. Thank you www.hfgproject.org

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