financing health in the context of protecting poor: myanmar experiences dr. phone myint

Financing Health in the Context of Protecting Poor:

Myanmar Experiences

Dr. Phone Myint

Seminar on Financing Health Care for the PoorUniversity of Public Health 15,16 November 2011

Outline

Financing health in MyanmarEvolutionNHA Estimates

Health and PovertySocial protection for reducing povertyHealth and social protectionHousehold health expendituresMoving towards universal coverage

How social protection addressed in the National Health Plans

What for the Future


Financing health in MyanmarEvolution and Reforms

Following independence from the colonial rule in 1948 health service provision more or less followed the British system

Health care services funded mainly by general government tax revenue

In districts local funds were established and managed by the local authority

Health services were provided free.



Social Security Scheme was started in 1956 according to 1954 Social Security Act

Composed of social health insurance services and implemented by the social security board under the Ministry of Labor

The only prepaid system in providing health care services



During the 1960s International assistance formed other source for financing health Support particularly provided for disease control activities such as TB campaign and Malaria campaign

Government taxation remained the major source of finance for health sector

Private sector started to grow during that period and registered doctors provided health care services both ambulatory and institutional



Following political changes in 1988 reforms in the health sector took place including financing reforms

Generally financing reforms can be classified into six different types

(1) Paying wards or rooms in public hospitals(2) User charges for Government Drug Supplies from CMSD(3)User fees for diagnostic services such as laboratory, X-ray, ECG(4) Community Cost Sharing (CCS) for essential drugs(5) introducing private service by in service staff at public hospitals(6) establishment of Trust Funds

Health services other than curative, i.e. public health services like promotive and preventive services including immunizations are still provided free by the government.


Financing health in MyanmarEvolution and ReformsCommunity Contribution

Important source of financing, in Myanmar context

Aged old tradition in Myanmar for the community to donate or contribute for the welfare of the society

Individual donor or collectively by the communityIn cash in or kind and ranging from medicine and hospital equipment to buildings and land

A number of hospitals in rural settings (station hospitals) have been built on this basis

Amount contributed for the whole country, in monetary value is still to be documented, system of proper and complete recording and registering still to be improved


Community Based Health Financing (CBHF)Indermohan S Narula, 1998 Review of the Community Health Management & Financing (CHMF) Initiative and the Community Cost Sharing (CCS) Approach in Myanmar: a strategic perspective;

Consultancy Report UNICEF Myanmar Mid-Term Review

DescriptionCBHF aims to meeting community's financing needs through pooling of resources to pay for health care as a group

Myanmar ExperiencesTypes

* Government Sponsored/Initiated* Cooperatives (Government supported/subsidized)* Community Initiated

Government Sponsored/Initiated

Community Cost Sharing Schemes implemented with support from various organizations since 1990.

* Community Health Management and Financing (CHMF)* Myanmar Essential Drug Project (MEDP)* Human Development Initiative-Extension (HDI-E)* Central Medical Store Depot (CMSD)* Family Planning International Association (FPIA)*Trust Funds

Observations• Lack of clear policy, guidelines and procedures for operating RDFs as the

key cost recovery mechanisms

• Lack of well designed exemption mechanism that includes guidelines and procedures

• Absence of meaningful subsidies at the lower levels of the health care system to support exemptions

• Lack of unified mechanism within the DoH to formalize and coordinate the various RDF and cost sharing projects

• Lack of coordination between donors supporting/implementing CCS based projects and activities

• Involvement of community-questionable

Cooperatives (Government supported/subsidized)

• Under the Ministry of Cooperatives

• Village/Wards base

• Township base

• Voluntary Memberships

• Agriculture/fishery/commodity production

• Health care provision-clinics-price reasonable and affordable ; quality

drugs available

• Government subsidized

• Defunct

Community Initiated

Donations (individual/collective)• Land • Building/maintenance• Medicine• Equipment• Furniture• Cash

Financial support as a social network • Funeral assistance• Loan for health care payment• Financial support for health care payment

Strength• Community kinship• Willing to help• Altruism

Weakness• Fragmented• Unsustainable• Lack/poor capacity in financial and overall management• Weak financial capacity • Lack of leadership

•

Financing health in MyanmarNational Health Accounts Estimates

Total (national) health expenditures growing annually

Government health expenditures growing annually-but not as supposed to be

Private household health expenditure constitutes major (more than 80%) of total health expenditure

Virtually all of household health expenditures made from out of pocket payment

Potentially catastrophic (impoverishing)


Systems of Health Care Financing

Health Care Providers

Risks-Pooling Entity

Tax Collector Social InsuranceRevenue Collector

Employers and Consumers

General Taxation

Social Insurance PHI

OOP

•

Health and PovertySocial protection for reducing povertyHealth and social protection


Individuals, Households, Communities, Nations

Being Poor

High level of exposure to risk of adverse events

Lack of means to cope with them

ABILITY

To avoid major shocks

To mitigate their impact

To cope with consequences

POVERTY

Unforeseen events-natural disasters, economic crisis, internal strife, etc

Sickness, Catastrophic Health Expenditure

SHOCKSIatrogenicPoverty

•

Health and PovertyHousehold health expenditures: protecting poor

WaiversTrust funds

Social networkExpenditures mostly made from existing income and household savings Relatives and friends also source of finance

Some households had to sell their asset the number is not significantly large

Traditionally the households, particularly in rural settings, have a good social network from which they can seek support in time of need.


•

Integrated Household Living Conditions Survey in Myanmar (2009-2010) Poverty Dynamics Report

Poverty dynamics-flows of persons into and out of poverty, not simply the stock of poverty at one or more given points of time

Storms, floods and stagnant water- more closely associated with entry into poverty than with chronic poverty

Chronic poverty more closely associated with droughts

Households escaped poverty-less affected by storms, floods and stagnant water

Health related shocks are not major causes of impoverishmentChronically poor are not poorest of the poor with respect to health and nutritional outcomes


•

Moving towards universal coverage

Government has increased health infrastructure, facilities and manpower to expand health coverage

Expansion of coverage through introduction of prepaid financing methods may not be expected overnightInterim measures, practical and feasible should be attempted

Exploring strength and weakness of the existing waiver system followed by modification and improvement

Identification of essential health care package, to be provided through community based health insurance in pilot townships followed by replicationsLimiting benefit package to essential care may lessen financial requirement to some extent


•


NHP (2006-2011)Policy Framework

HFAUniversal access based on PHC concept/approachesPriority to rural and border areasA system for financing health

protect financial burdenequitableaccess to allsuitable to socio-economic situations of the country


•


HCF Component in the NHPObjectiveTo enable to explore and develop an appropriate and sustainable financing mechanism for health that would provide sufficient amount of fund

StrategiesPromoting sectoral collaboration in financing healthPromoting collaboration by communityPromoting role of private sector and NGOs in conformity with rules and regulations


•


ActivitiesTrainings and workshopsNational Health AccountsHealth financing studiesFeasibility study to introduce appropriate health insurance system in the country


•

What for the Future


•

What for the FutureHealthBasic human right

A battle ground on which competing visions of the ethical and political basis of society are fought, in the struggle for developmental, inclusive and democratically rooted social policy

Health policy is part of a broader social and public policies

Health systems are the institutional expressions of these policies, rooted in legal rights, values and political commitmentsHealth system

health carepublic healthhealth promotionassessment of health implications of other policies


•

What for the Future Aims of health services

universal access according to needsolidarity in provision and financing

Health sector reforms across the world Using market mechanisms in provision of health servicesSeeing health care as a private good

Commercialized health care Provision through market relationships to those able to payInvestment in and production of servicesFor cash income or profit


What for the FutureBasic principles (values) in various Constitutions

Enhancing the eternal principles of Justice, Liberty and Equality in the Union (2008)

Opposing all pernicious systems characterised by exploitationof man by man, and of one national race by another, with a view to promoting justice and goodwill among the people, and to freeing them from apathy and callousness, ignorance, backwardness and want of opportunity (1974)

To maintain social order on the basis of the eternal principles of JUSTICE, LIBERTY AND EQUALITY(1947)


financing health in the context of protecting poor: myanmar experiences dr. phone myint

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