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Fair and Sustainable Health Financing Mohammed Shaheen School of public health AlQuds University Background 1. Sustaining health financing is a big challenge in all countries specially in poor and politically instable countries. 2. There is no best model for health care financing it should try to address the different dimensions of country context on continuous basis. 3. The challenge is how can we balance quality of care (efficiency & effectiveness), risks, equity, acceptability with health care cost. Health Challenges 1. Poor countries are facing huge excess premature mortality, low life expectancy and most of the Health MDG targets are not met 2. Foe example; 80% of the 11 million deaths per year that occur in Africa results from preventable diseases 3. HIV/AIDS, lower respiratory tract infection, malaria, diarrhoeal diseases and maternal and prenatal conditions accounts for 54% of the deaths 4. This heavy burdens of disease have contributed significantly to chronically poor economic performance and poverty in poor countries. Socio-Economic Context - Poverty 1. For example: More than 50 percent of the countries in the African region are severely indebted 2. Big informal sector and high unemployment 3. High levels of poverty and inequitable distribution of income; the human poverty index is 40% 4. 44% of population are living on less than one USD per day Water, Education and Sanitation 1. 40% of the population lack access to safe drinking water 2. 40% of adults in the region are illiterate 3. Primary school enrolment is 63% and secondary school enrolment is 21% 4. 47% of the population in the region lack access to adequate sanitation facilities Total Health Expenditure 1. African countries spend in average 5.7% of their GDP on health, (same as in 1995, 8.2% for all countries worldwide) 2. 35 countries (76% of all) spend less than USD 34 per capita, regarded as the minimum for providing an essential health care package 3. The proportion of governmental health spending of total government spending is 8% 4. 44 countries (96% of all) spend less than 15% (Abuja benchmark) of national budgets on health Private/Public Health Expenditure 1. Private health expenditure amounts to be 56% of total health expenditure (2 times more than in Europe) 2. The health systems of most African countries depend largely on household’s direct out-of-pocket payments; averaged 28% of total health spending 3. Government spending on health is 44% of the total health expenditure 4. The poorest and most indebted countries rely heavily on external resources; 28% of total governmental health expenditures (4% in richer countries) Prepayments 1. 17 countries in the region (35% of all) are using some type of pre paid plans 2. Few countries in the region have introduced social health insurance schemes; corresponding to 3% of the total health expenditure 3. Several countries in the region have been implementing community health insurance schemes and some medical savings accounts Health Financing Challenges 1. Failure of establishing cost recovery safety net mechanisms in protecting the poor 2. Lack of financial resources to produce good health for all 3. Low income countries have a small revenue base to generate domestic resources 4. Inefficient use of available health resources 5. Lack of human resources is a major bottleneck in achieving efficient health care Health Financing Challenges 6. High turnover of health staff, mainly due to poor financial incentives 7. Weak management capacity to provide essential and quality health care services 8. Limited technical capacity to manage complex health financing and equity issues 9. Weak monitoring and analytical capacity and evidence not being used in health policy making and management HEALTH SYSTEM FRAMEWORK FUNCTIONS Stewardship Oversight Resources OUTCOMES Responsiveness People’s non-medical expectations Investment and training Delivering services Health Provision Financing Collecting, Pooling, Purchasing Fair financing Health Financing Functions Pooling Purchasing/ payments Service providers Collection Population resource base GDP Out-of-pocket Private Insurance Co-payments Companies Labor Market External Aid Natural Resource Revenues Capitation Income Tax Systems Region Voluntary Prepayment Demographics Mandatory Prepayment Economic Activity Health Risk Fee for Service Professionals NGOs Public Insurance Agencies Centrl Government Indir Taxes Local Governments Direct Taxes Public/private facilities Budgeting NGOs Salaries Hospitals Prospective Districts Retrospective Health Financing Instruments 1. General tax revenue/earmarked taxes 2. User fees (cost-sharing/cost-recovery) 3. Health insurance - Social - Community - Private 4. Medical savings accounts 5. Donor funds Fair and Sustainable Health Financing 1. Financial protection - Reduce the risk that households will face catastrophic health expenditures - Cross subsidisation of the poor and vulnerable by healthy and wealthy sectors of society - Minimize large out-of-pocket spending on health, such as user fees - Introduce or strengthen prepaid plans such as health insurance and publicly subsidised services Fair and Sustainable Health Financing 2. Improve equity and efficiency in allocation, access to and utilization of existing health care resources 3. Increase external and domestic funding to benefit the poor - Mobilize domestic resources by using efficient revenue collection methods 4. Optimise the use of different financing sources and payments mechanisms to create balanced incentives for health providers with regard to equity, efficiency, productivity and quality of health care delivery Contextual Approach Recognize the importance of the country's: 1. Health situation and epidemiology 2. Structure and capacity of the health system 3. Macroeconomic constraints 4. Socioeconomic conditions 5. Cultural values 6. Political situation Integration - Interaction Health financing strategies and action plans to be developed with reference to: 1. National Health Policies and Strategies 2. Millennium Development Goals (MDGs) 3. Poverty Reduction Strategy Paper (PRSP) frameworks 4. Collaboration between governments and development partners, guided by the Paris Declaration of 2005 of Alignment and Harmonization, e.g. effectiveness, division labour, use of SWAps of Use of Evidence Based Information 1. Analysis of current levels of health spending, sources and the use of those sources (NHA data) 2. Economic viability analyses of various financing options 3. Health policy analysis 4. Legal analysis 5. Socio-political environment analysis 6. Training and research Implementation Constraints 1. High disease burden and high levels of poverty 2. Huge informal sector, high unemployment and narrow tax base 3. Lack of human resources and management capacity in health care 4. Limited analytical capacity in monitoring and evaluation 5. Limited evidence based data available for use in health policy and management Enabling Factors in Implementation 1. Strong political commitment 2. Acceptability to clients, professionals, politicians, collaboration partners and the general public 3. Proper management, monitoring and evaluation Enabling Factors in Implementation 4. Good governance, transparency and accountability 5. Active partnership, coordination and collaboration between governments, development partners, training and research institutions 6. Adequate financial and technical support