Health Reform, Health Financing, and Population Health

1. Health Reform, Health Financing, and Population Health Dominic S. Haazen, Sr. Health Specialist, The World Bank Riga, Latvia

2. Presentation Outline • Program of Action elements relevant to this discussion • Key health reform interventions in the countries in transition • Developments in health financing and payment systems • Recent developments in HIV/AIDS • Implications for population health

3. Program of Action – ICPD 1994 • universal access - primary health care • universal access – comprehensive reproductive health services • including family planning • reductions in infant, child and maternal morbidity and mortality • increased life expectancy

4. Accomplishments – ICPD+5 1999 • population concerns integrated into development strategies in many countries • mortality in most countries continued to fall • broad-based definition of reproductive health increasingly accepted • steps being taken to provide comprehensive services in many countries • increasing emphasis on quality of care • rising use of family planning methods • greater accessibility to family planning

5. Unfinished Agenda – ICPD+5 1999 • Still unacceptably high mortality/morbidity • HIV/AIDS • Infectious diseases, such as tuberculosis • Maternal mortality/morbidity • Adult NCD mortality for countries with economies in transition , especially among men • Adolescents particularly vulnerable to reproductive and sexual risks. • Lack of access by many to reproductive health information and services

6. Constraints/Needs – ICPD+5 1999 • financial, institutional, HR constraints • greater political commitment needed • national capacity must be developed, but increased international assistance is needed • more domestic resources must be allocated • effective priority-setting within each national context is an critical factor • integrated approach: policy design, planning, service delivery, research and monitoring

7. Action Items – ICPD+5 1999 • ensure social safety nets are implemented • strengthen specific health programs: • infant/child health programs that improve prenatal care and nutrition, • maternal health services, • quality family-planning services • efforts to prevent transmission of HIV/AIDS and other sexually transmitted diseases;

8. Action Items – ICPD+5 1999 • strengthen health-care systems to respond to priority demands • ensure resources are focused on the health needs of people in poverty • develop special policies and health promotion programs to address rising or stagnating mortality levels • strengthen national information systems to produce reliable statistics in a timely manner.

9. Key Health Reforms – ECA Region • Introduction of primary health care • Decentralization of health facilities • Health insurance (various models) • Provider payment reforms • Rationalization of health services • Hospitals, EMS, PHC, specialists • Introduction of health promotion and prevention approaches, strategies • Adoption of DOTS

10. WB Supported Interventions – 1991-2001

11. Health Financing Dimensions • Revenue raising – amount/method • Pooling of funds • Resource allocation • Coverage/benefit package • Out of pocket payments • Purchasing methods

12. Health System Financing & Population Links

13. Revenue Raising Methods • payroll tax emerged as a standard source of health care financing • 14 countries have payroll taxes: 9 as main financing mechanism, 5 as complementary • contribution rates range from 2% in Kyrgzstan to 18% in Croatia • 7 countries rely primarily on taxation • Out-of-pocket costs range from less than 20% in Slovenia and Croatia to over 80% in Georgia and Azerbaijan

14. Out of Pocket Payments in ECA

15. Out of Pocket Payments - Impact • OOP payments affect treatment choice • riskier interventions such as surgery require larger payments • Services that may be seen as discretionary (pre- and post-natal care), may be avoided • Quality of care and waiting times may depend on ability to pay • Undermines universality of publicly financed health programs

16. Revenue Raising Capacity …

17. … and Impact on Health Spending

18. Public Health Spending vs. GDP

19. Coverage – “Basket of Services” • Many/most countries have attempted to define, but with limited success • 14 studies funded through WB alone • e.g., Armenia - universal coverage only for primary/emergency services; some secondary services available only for the poor • Even when defined, non-poor often benefit disproportionately • Definition of “emergency” in Armenia • Urban-rural disparities in access

20. Payment Methods – Physician Services

21. Payment Methods – Physician Services

22. Payment Methods – Inpatient Care

23. Payment Methods and Incentives

24. Provider Payment Methods - Impact • Any one method by itself does not satisfy all objectives • Additional incentives are needed to address those inherent in selected approach • More sophisticated methods often require information systems that may not (yet) be available in transition countries

28. HIV/AIDS Regional Support Strategy • Raising political and social commitment • Generating/using essential information • Estimating the economic and social impact • Improving surveillance • Maximizing value for money • Estimating resource requirements • Prevention of TB and HIV/AIDS • Harm reduction, focus: CSW, IDU, prisons • Sustainable, high quality care • Facilitating large-scale implementation

29. Implications for Population Health • Unfinished rationalization agenda: • Misallocation of resources • Service quality (incl. reproductive health) • Under-funding of PHC and prevention • Limited public funding in many countries • Reproductive health must compete • Challenge to ensure access for poor/rural • Provider payment systems incentives • Must encourage RH related activities

30. Implications for Population Health • Primary health care “immature” • Obs./Gyn. specialists still do most RH • Public confidence in PHC abilities • Information systems tell us little about what is going on (“known unknowns”?) • Amount of ante-natal/post-natal care • Other reproductive health activities • Hospitalization (ALOS, C-section, comp.) • Disease surveillance

31. Thank you!! Dominic S. Haazen, Sr. Health Specialist, The World Bank Riga, Latvia dhaazen@worldbank.org