april 2013 1 |1 | tessa tan-torres edejer health systems financing priority setting in universal...
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Tessa Tan-Torres EdejerTessa Tan-Torres EdejerHealth Systems FinancingHealth Systems Financing
Priority Setting in Universal health coverage:
Choosing services
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The Three Dimensions (policy choices) The Three Dimensions (policy choices)
Universal Health
Coverage
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How does one choose needed services?How does one choose needed services?
What types of services to consider:– preventive, promotive, curative, rehabilitative, palliative– Across the life course– Across different levels of health facilities– procedures and pharmaceuticals and other medical goods– positive or negative lists
Main criterion:– Cost-effectiveness to maximize health; Getting the most out of the available
funding– Quantifying opportunity costs when choosing less cost effective interventions
Implementation issues:
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Millions miss out on needed health servicesMillions miss out on needed health servicesPercentage of births by medically trained personsPercentage of births by medically trained personsMillions miss out on needed health servicesMillions miss out on needed health services
Percentage of births by medically trained personsPercentage of births by medically trained persons0
20
40
60
80
100
0 10 20 30 40 50
Q1Q5 Average
Source: Latest available DHS for each country (excl. CIS countries)
Q1, Q5 and Average - 22
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MDG Tracer Conditions: MDG Tracer Conditions: CEA threshold defined de facto? CEA threshold defined de facto?
MDG Tracer Conditions: MDG Tracer Conditions: CEA threshold defined de facto? CEA threshold defined de facto?
Antenatal care: 4+ visitsBirth attended by skilled health personnelMeasles, DTP3, Hib3, HepB3Children < 5: ARI visit; sleeping under ITN; ORT diarrhoeaART HIV; MCTC HIV + pregnant womenTB: case detection rateAdditional as possible (based on burden, CEA threshold,
budget, logistical feasibility)
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But cost-effectiveness is not that straighforward:
But cost-effectiveness is not that straighforward:
Cost-effectiveness might correlate with the other axes.– Many cost-effective interventions are for traditional diseases of the poor– But many cost-ineffective interventions are costly (trauma surgery, cancer
drugs, renal replacement therapy)
Cost-effectiveness may change:– Because of drop in prices due to national/global volume of sales /international
pressure (tiered pricing)– Because of bundling of services (economies of scope); – Start up costs- special problem
Even if cost-effective, it may still not be affordable (budget constraints)
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Shifting from pure cost-effectiveness to cost effectiveness ++
« Quantitative analysis for qualitative insight »
Shifting from pure cost-effectiveness to cost effectiveness ++
« Quantitative analysis for qualitative insight »
Begin from CHOICE results (cluster of disease or health sector as a whole)
Use checklist to identify excluded interventions of equity or priority setting interest
Use quantitative techniques to explore concerns & illustrate impact of alternative choices
– What resources will be released or foregone?
– What existing treatments will have to be displaced?
– What health benefits will be foregone?
– What is society willing to pay for a more equitable choice of interventions?
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Example: Mental health (cluster)Example: Mental health (cluster)
At a mental health budget level of $3.50 per capita (India), efficiency results from CHOICE suggest funding the following conditions:
– Epilepsy
– Alcohol treatment
– Depression treatment
No funding would be allocated to treatment of bipolar disorder or schizophrenia on efficiency grounds alone
However, equity & priority-setting considerations (checklist):– Conditions severe, chronic, lifelong
– Not curable, limited capacity to benefit
– Bad luck in the health lottery
– Interventions are the only means to help
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Example: Mental health (cluster)Example: Mental health (cluster)
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Implementation issuesImplementation issues
There are already pre-existing services being provided by governments of varying cost-effectiveness; e.g SHI providing coverage for hospitalization with a cap; no description of the disease or intervention being covered (subsidy).
Administrative ease
The patient does not know on consultation what diseases s/he has or what procedure/medication will be needed
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0 100 200 300 400 500 600 700 800
Investigation of signs,symptoms and other contact
Infectious and parasitic
Injuries
Chronic respiratory disease
Respiratory infections
Cardiovascular
Digestive system
Skin diseases
Nervous system disorders
Genitourinary
Musculoskeletal
Malignant neoplasms
Diabetes mellitus
Nutritional deficiencies
Mental disorders
Neonatal causes
Oral health
Blood/Immune Disorders
Congenital anomalies
Endocrine and metabolic
Benign neoplasms
Maternal conditions
Expenditure per capita (Rupees)
Female
Male
Health expenditures by conditionSri Lanka 2005
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Fig. 2. Health care choices in a low-income and middle-income country. The vertical axis indicates the level of public subsidy, the right-side horizontal axis refers to the population volume classified as poor and non-poor, and the left-side horizontal axis represents clinical health services divided into the minimum and the essential packages. Public subsidies should be close to 100% for the minimum package for the poor. In low-income countries the subsidy should fall, perhaps quite sharply, as resources extend to the non-poor or to interventions outside the minimum package. In middle-income countries the subsidy could extend to the non-poor and can finance part of the essential package only if the minimum package is
assured for the poor and all cost-effective services are covered for the entire population (WDR93).
LOW-INCOME COUNTRY
iNCOME Minimumpackage Essential
package
Totalpopulation
S/DALY
Public fiannce share
MIDDLE-INCOME COUNTRY
Income Minimumpackage
Essentialpackage
Totalpopulation
Poverty line
Public fiannce snare
S/DALY