Download Health Financing Options for Sudan

The Republic of Sudan:
Health Financing Options
Karima Saleh, PhD
Senior Economist (Health),
World Bank, Washington, D.C.
Presented at the UHC Conference in Sudan, January 23, 2017
Khartoum, Sudan
Plenary session 3: Health Financing Profile
Life expectancy of Sudan
is worse than other countries of similar income, 2013
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Health Outcomes in Sudan
are worse than other countries of similar income, 2013
Maternal mortality
Maternal mortality ratio (100,000 live births)
200
400
600
800 1000 1200
Under five mortality rate (1,000 live births)
50
100
150
200
Under-5 child mortality
Nigeria
Uganda
Pakistan
Sudan
Kenya
Ethiopia
Tanzania
250
1000
Algeria
Iran, Islamic Rep.
Jordan
Libya
Tunisia
Lebanon
2500
10000
25000
GDP per capita (current US$)
100000
Tanzania
Uganda
Kenya
Sudan
Pakistan
Morocco
Algeria
Tunisia
Jordan Lebanon
Egypt, Arab Rep.
Libya
Iran, Islamic Rep.
0
0
Morocco
Egypt, Arab Rep.
Nigeria
Ethiopia
250
1000
2500
10000
25000
GDP per capita (current US$)
100000
3
Public health spending in Sudan
is worse than other countries of similar income
Household out-of-pocket spending on
health as share of total health spending –
limited financial protection
Public health expenditure (% of GDP)
5
10
15
20
Public spending on health as share of
GDP
Jordan
Algeria
Uganda
Tunisia
Ethiopia
Tanzania
0
Kenya
Pakistan
Lebanon
Libya
Morocco Iran, Islamic Rep.
Egypt, Arab Rep.
Sudan Nigeria
250
1000
2500
10000
25000
GDP per capita (current US$)
100000
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Challenges in Revenue Collection for Health
Does Sudan have sufficient and
sustainable public financing for health?
Who is bearing the burden of health
care cost?
• Low and insufficient
• 2.4% of GDP (2013)
• 21% of total health spending (2013)
Benchmark = 4-5% of GDP for UHC
• Health Insurance Program (NHIF, SHI) have
limited contributions
• Public HI = 4% of total health spending,
2011
• Private HI = 1% of total health spending,
2011
• Fluctuations in annual budget for health
• From 12.4% (1998) to 11% (2013), health
spending as share of total government
expenditure
• Benchmark = 15% of government budget
(Abuja Target)
• Inequitable health resource allocations by
states
• Low financial protection for health
• Household out-of-pocket spending= 76%
of total health spending, 2013
• Benchmark=15-20% of total health
spending
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Challenges in Pooling of Resources for Health
Are resources managed to equitably
create pools?
Are resources managed to efficiently
create pools?
• Limited coverage: the poor are not entirely
pooled (50% covered) due to limited financing.
• Limited coverage: near poor not covered due to
unaffordability (not subsidized).
• Limited pools: informal sector is not pooled,
voluntary health insurance – adverse selection.
• Limited enforcement: Formal sector not
entirely pooled despite mandatory health
insurance program – weak enforcement.
• Regressive: flat premium rates for informal
sector; the lower income groups pay as much as
the high income groups.
• Fragmentation of resource pools creates
inefficiency
• Multiple pools (NHIF, SHIS, Private HIS,
FMOH, SMOH)
• Fragmentation of resource pools creates
different incentives
• Fixed (salary) and variable (operations)
budgets are separated
• Vertical fund flows
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Challenges in Purchasing of Services for Health
Are resources used in an allocative
efficient manner to purchase value for
money?
Are resources used in a technical efficient
manner to purchase value for money?
• More public resources are spent on hospitals
instead of primary health care.
• Inequitable distribution of staff in favor of
urban areas and hospitals
• Significant resources are spent on fixed
budgets (salaries, 60%, 2011) versus variable
budgets (operations)
• Low investments in primary health care,
thereby, patients bypass and favor hospitals
over primary health care for outpatient care
• Limited use of generic drugs
• Fragmented purchasing
• Fee for service payment has a tendency to
create more and unnecessary spending
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The way forward for Sudan…..
Need a structured protocol for reviewing policies to:
• (1) manage the benefits package;
• (2) manage inclusion of the poor and vulnerable groups;
• (3) improve efficiency in the provision of care;
• (4) address challenges in primary care; and
• (5) adjust financing mechanisms to better align incentives.
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Health Policies will need to emphasize:
• making entitlements explicit;
• establishing enforceable guarantees;
• instituting supply side incentives aimed at improving quality of care;
• reducing geographical barriers to access;
• efforts to enhance governance and accountability.
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…and to address challenges
• To reduce fragmentation in the financing and organization of health
systems,
• To harmonize the scope and quality of services across subsystems,
• To leverage public sector financing in a more comprehensive and
integrated manner, and
• To create incentives that promote achievement of improved health
outcomes and financial protection.
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Some lessons learnt from international findings on
UHC
• larger quantities of pooled financing that focus on equity are necessary
conditions to progress toward UHC;
• financed largely if not entirely from general revenues that prioritized or
explicitly targeted populations lacking the capacity to pay;
• increase in public financing for health as a share of GDP;
• Political commitment translated not only into larger budget allocations but
also into the passage of legislation that ring-fenced funding for health by
establishing minimum levels of health spending, labeling or earmarking taxes
for health;
• moved partially away from input-based, line-item budgets toward per capita
transfers, sometimes derived from actuarial cost calculations. Such
mechanisms are known to reduce uncertainty in financing;
• policies to improve the incentives and governance framework with the
objective of increasing efficiency and expanding access to health care,
particularly among the poor and those at risk of falling into poverty because
of health care costs.
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Some policy considerations for Sudan
Essential Health Benefits Package (EHBP)
• Streamline EHBP to be financed through
prepayment;
• To identify EHBP: Use a methodology that
takes into consideration - burden of disease,
cost effectiveness, equity consideration, and
financial protection;
• Proposed Content of EHBP, for example:
• PHC (5 elements)
• Emergency service
• Cesarean section
• Selected high cost / catastrophic services
(e.g. renal dialysis, cardiovascular,
oncology) for selected population
• Cost out the EHBP.
Financing Options
• Consider financing options for coverage of this
EHBP (modify EHBP according to what finances
may be available);
• Identify and simulate various sources of financing
that are progressive and pool: budget, zakat fund,
payroll contribution for formal sector workers,
other copayment/ premiums for outside EHBP
services and drugs (for hospitals);
• Consider a phased approach for coverage, and
budget needs within the fiscal constraint;
• Prioritize coverage and financing of the poor,
streamline identification mechanisms.
Purchasing Options
• Consider service delivery readiness (HRH,
investment, supply chain) and incentivize;
• Consider purchasing options and ways to improve
efficiency and cost containment.
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Summary:
• Leverage public financing to reach the poor
• A pragmatic and contextual approach to define (or not) the benefits
package
• Increase public financing for health
• Reforms in the way providers are paid and managed
• Emphasis on primary care
• Tackling equalization across subsystems
To achieve universal health coverage, need to provide
“coverage that everybody is guaranteed to receive”
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• Thank You!
• Shukrun!
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