Health Reform Health Financing and Population Health Dominic

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

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

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

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

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

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

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;

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.

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

WB Supported Interventions – 1991 -2001

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

Health System Financing & Population Links

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

Out of Pocket Payments in ECA

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

Revenue Raising Capacity …

… and Impact on Health Spending

Public Health Spending vs. GDP

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

Payment Methods – Physician Services W. Europe All Hospital O/P Specialist PHC Salary Finland Portugal England Ireland Italy Denmark Germany England Ireland Italy Sweden Fee-for-service France Belgium Germany Sweden Germany Capitation/FFS Capitation/Salary Flat Rate/FFS England Ireland Denmark Spain Austria Italy

Payment Methods – Physician Services ECA Region Salary Fee-for-service FFS/Volume limit All Hospital O/P Specialist MD, BY, TM, TJ, AZ SI, AL, CZ, AM, RO, BG SI, AL GE, LV LV, LT, PL, RO, BG CZ Capitation/FFS PHC AL, PL, HU GE CZ, RO, BG, EE, SI, SK Capitation/Bonus GE, EE, LT Capitation/Fundholding LV

Payment Methods – Inpatient Care

Payment Methods and Incentives Mechanisms Incentives for Provider Behavior Prevention Line Item Budget Fee-for-Service Per Diem Per Case (e. g. , DRG) Global Budget Capitation Service Delivery Cost Containment

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

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

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

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

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