presentations during a national universal health coverage...
TRANSCRIPT
Presentations during a National Universal Health Coverage
Advocacy Symposium
Taj Pamodzi Hotel Lusaka, Zambia30th June and 1st July 2015
Table of Content
1. Overview of UHC in ECSA Region-ECSA Secretariat
2. UHC as a Policy Issue in Zambia Now and Beyond-MOH Zambia
3. Government Financial Allocation-MOF Zambia
4. Health Financing Strategy and Social Health Insurance in Zambia-MOH
5. Research and existing evidence-University of Zambia
6. Defining Zambia’s Proposed SHI Package-NHI coordination unit
East Central and Southern Africa Health Community
Advocacy symposium on Universal Health Coverage
Overview of UHC in ECSA Region
Taj Pamodzi Hotel, Lusaka Zambia
30th June- 1st July 2015
Dr Walter Denis Odoch
Manager, Health Systems and Services Development Program, ECSA
Presentation Outline
- Overview of East, Central and Southern Africa Health Community (ECSA-HC) structure
- Objectives of the advocacy symposium on UHC- UHC in ECSA Member states
4
East Central and Southern Africa Health Community
5
- Inter-governmental regional health organization established in 1974 under the auspices of the Commonwealth Secretariat, London to foster and promote regional cooperation in health among Member States
- Commonwealth Regional Health Community for East, Central and Southern Africa (CRHC ECSA)
- From 1980, it has functioned under the direct control of Member State governments
- In Nov 2002 Health Ministers Conference adopted the name ECSA-HC- Active member states: Kenya, Lesotho, Malawi, Mauritius, Swaziland, Tanzania,
Uganda, Zambia and Zimbabwe.
East, Central and Southern Africa Health Community
ECSA-Health Community structure
Expert Committees Directors Joint Consultative Committee (
ECSA Secretariat
Advisory Committee
Conference of Health Ministers
Symposium Objectives
To contribute to existing global and regional efforts on UHC and energize the local discourse with a view of increasing resources and its efficient use in the health sector though establishing and/or facilitating country level advocacy efforts for UHC.
- Creating awareness among key stakeholders about UHC
- Act as an advocacy event for the UHC in the member state
7
East Central and Southern Africa Health Community
Socioeconomic development and health; Need for UHC
- Good health is essential to sustained economic and social development
and poverty reduction.
- Access to needed health services is crucial for maintaining and
improving health.
8
East Central and Southern Africa Health Community
Socioeconomic development and health; Need for UHC
- Governments and development partners are engaging in political and
technical discussions on how to expand health coverage.
- Need for Reforms:- legal, financial, and political considerations to
determine the best approaches.
- Details vary from country to country, common goals• cost burden of health care is shared widely and equitably,
• patients and their families have increased coverage,
• resources are better utilized, and health outcomes are improved.
9
East Central and Southern Africa Health Community
Commitments to increasing Health Coverage- World Health Assembly (WHA) 2005
resolution, WHA 58.33
- WHA Resolution on primary health care (WHA 62.12),
- WHA Resolution on Social Determinants of Health (WHA 62.14)
- The Pan African Congress on UHC
- UNGASS resolution on affordable universal healthcare.
10
East Central and Southern Africa Health Community
- 2010: HMC52/R2:Universal Health Coverage
- 2010: HMC50/R1: Health Insurance and Financing
- 2008: HMC46/R1: Strengthening Health Systems to Ensure Equitable Access to Health Care
- 2003:HMC/42/R5.1 and R6: Resource Mobilization and Alternative health financing
Tracking commitments on increasing Health Coverage
- Need for clear Goals:
- shape political agendas and influence resource transfers
- The way goals and indicators are defined influences how the world understands
development
- Health is central to development: it is a precondition for, as well as an
indicator and an outcome of progress in sustainable development
11
East Central and Southern Africa Health Community
Universal Health Coverage (Proposed SDS goal 3)
GOAL 3: Ensure healthy lives and promote wellbeing for all at all ages
All countries achieve universal health coverage at every stage of life, with
particular emphasis on primary health services, including mental and
reproductive health, to ensure that all people receive quality health
services without suffering financial hardship. ………
12
East Central and Southern Africa Health Community
Universal Health Coverage; Three things;-
- All people having access to health services that they need
- Health services being of sufficiently good quality
- People access health services without the consequence of financial
hardship
13
East Central and Southern Africa Health Community
How do you judge progress
14
East Central and Southern Africa Health Community
Strategies towards UHC
- Raise sufficient funding for health:- Mobilize more resources both locally and internationally
- Reduce the reliance on direct payments to finance services:- Remove financial risks and barriers to access through prepayment and pooling mechanisms
- Promote solidarity of the whole population whereby the rich subsidize the poor, and the healthy subsidize the sick
- Improve efficiency and equity:- Promote efficient use of available resources and eliminate waste
- Increase the quality of health services
15
East Central and Southern Africa Health Community
ECSA Member States; how are we doing in financial protection
16
Per capita total expenditure on health at average exchange rate (US$)
0
50
100
150
200
250
300
350
400
450
500
Tanzania Zambia Kenya Lesotho Malawi Mauritius Swaziland
US
D p
er
pe
rso
n p
er
ye
ar
2006 2008 2010 2012 2013
ECSA Member States; how are we doing in financial protection
17
20.0
25.0
30.0
35.0
40.0
45.0
50.0
55.0
60.0
65.0
70.0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
en
t
Years
United Republic ofTanzania
Zambia
Kenya
Lesotho
Malawi
Mauritius
Swaziland
Private Health Expenditure as % of Total Health Expenditure
ECSA Member States; how are we doing in financial protection
18
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
en
tOut of Pocket expenditure as a Percentage of Total Private Health Expenditure
Tanzania
Zambia
Kenya
Lesotho
Malawi
Mauritius
Swaziland
ECSA Member States; how are we doing in service coverage
19
0
10
20
30
40
50
60
70
80
90
100
Kenya Lesotho Malawi Mauritius Swaziland Tanzania Zambia Zimbabwe
Pe
rce
nt
Percentage of birth attended by a skilled health personnel
2005 2007 2010 2014
ECSA Member States; how are we doing in terms of Impact
20
0
200
400
600
800
1000
1200
2000 2005 2008 2010 2012
Ma
tern
al D
ea
th p
er
10
0,0
00
liv
e b
irth
Year
Kenya Lesotho Malawi Mauritius Swaziland
Tanzania Uganda Zambia Zimbabwe
Maternal Mortality
ECSA Member States; how are we doing in terms of Impact
21
0
20
40
60
80
100
120
140
160
180
Kenya Lesotho Malawi Mauritius Seychelles Swaziland Tanzania Uganda Zambia Zimbabwe
Un
de
r 5
de
ath
pe
r 1
,00
0 l
ive
bir
th
2000 2005 2009 2012
Under five mortality rate
ECSA Secretariat Efforts
- Supporting regional monitoring and sharing of progress and best
practices on UHC in ECSA Health Community
- Catalyzing advocacy initiatives for UHC in the region
- Technical support in health financing reforms
22
East Central and Southern Africa Health Community
Conclusion
- In addition to the MDGs there are “new” issues (non-communicable
diseases, health systems, determinants of health and health security)
- UHC characterizes health in a broad sense, in a way that is measurable
and supports generation of political traction and public understanding.
- Universal Health Coverage is a dynamic process. It is not about a fixed
minimum package, it is about making progress on several fronts
23
East Central and Southern Africa Health Community
THANK YOU FOR YOUR ATTENTION
UHC as a Policy Issue in Zambia Now and Beyond
Ministry of Health Zambia
UHC AS A POLICY ISSUE IN ZAMBIA NOW AND BEYOND
26
30th June, 2015
SYMPOSIUM ON UNIVERSAL HEALTH COVERAGE
27
• Population – 15.02 million
• GNI 2012 US$ 1,550 per capita,
• Gini 0.62
• Health status
Life expectancy at birth- 50yrs M: 53 F
U5MR 75/1000 Live Births,
MMR 398/100,000 Live Births
Skilled Deliveries- 63%
• Fiscal space: Tax revenue 23% of GDP ,
• Gov’t health spending 9.9 % total budget (2015)
• Total Health Expenditure (THE)
US$ 112 per capita, 6.4% GDP
Source: Public 50%, External Resources 39%,
OOP 7%
Zambia: Country Profile
DEFINITION OF UNIVERSAL HEALTH CARE (UHC)
"Financing systems need to be specifically designed to:
Provide all people with access to needed health services (including prevention,
promotion, treatment and rehabilitation) of sufficient quality to be effective;
Ensure that the use of these services does not expose the user to financial
hardship"– World Health Report 2010, p.6
DEFINITION EMBODIES SPECIFIC AIMS (UNIVERSAL COVERAGE
OBJECTIVES)
Equity in service use;
Quality; and
Financial protection…
…for all
Promotes cross-subsidies in overall health system:
Everyone should benefit according to need for care
Everyone should contribute according to ability to pay
THREE DIMENSIONS OF UHC
1.
2.3.
TWO IMPORTANT COMPONENTS OF THE ZAMBIAN
FRAMEWORK OF HEALTH DELIVERY
1. A systems Approach
2. Universal Health Coverage Principles
Note: These are not exactly as espoused internationally but are
deliberately adapted to the local Zambian situation. The next
slides explain this
OBJECTIVES TO BE ACHIEVED
To address the issue of “under funded” health sector and barriers to accessing health
services, the GRZ is proposing to set-up and implement a National Social Health
Protection Scheme.
The National SHP scheme will enable all citizens of Zambia to access a comprehensive
package of quality health services on a timely manner and without financial hardship.
Zambia’s Policy Emphasis on the Wider Health Financing Agenda for UHC
Coverage of Financing for health: The Financing for Health program should not be for
the privileged, select few or the elite but for all i.e. the “Zambia National Health Service”;
Cash Flow: The design of the health financing strategy, including the SHI program must
be designed to withstand cash flow fluctuations in the sector so that there is no
interruptions in the flow of essential services to the people;
Drug Supply: The essential drug list must be appropriately designed to capture the
necessary drugs and this essential drug list must always be available;
Result Based Financing: The health financing must have an incentive based
financing/Result Based Financing mechanism;
The Poor and Vulnerable: The welfare of the poor and vulnerable as well as special
population groups such as the elderly and differently abled must be well secured in the
program.
Source: Dr. J. Kasonde, Hon Minister of Health, MP, April 2014
THE MAIN NHSP TARGETS FOR ZAMBIA
Reduce the under-five mortality rate from the current 119 deaths per 1000 live births to 63 deaths per 1000
live births by 2015;
Reduce the maternal mortality ratio from the current 591 deaths per 100,000 live births to 159 deaths per
100,000 live births by 2015;
Increase the proportion of rural households living within 5km of the nearest health facility from 54.0 percent
in 2004 to 70.0 percent by 2015;
Reduce the population/Doctor ratio from the current 17,589 to 10,000 by 2015;
Reduce the population/Nurse ratio from the current 1,864 to 700 by 2015;
Reduce the incidence of malaria from 252 cases per 1,000 in 2008 to 75 in 2015;
Increase the percentage of deliveries assisted by skilled health personnel from 45 percent in 2008 to 65
percent by 2015; and
Reduce the prevalence of non-communicable diseases associated with identifiable behaviours.
What is the social health protection
model being proposed in Zambia?
STRATEGIC FRAMEWORK
Phased approach in population coverage starting with the formal sector and vulnerable groups of population
and gradually extending coverage to all citizens of Zambia
Seek synergies with existing institutions and systems in a cost-efficiency approach
Coordination with other Social security programmes for contribution collection, identification of the poor and control
of compliance
Linkage with SCT scheme to cover the Vulnerable groups
Coordination with other Social security branches such as Pension or Maternity now being developed
Linkage with reformed pension scheme to collect contributions from the formal sector workers
Linkage with health system strengthening programmes and Health Professions council to improve and guarantee the
quality of services provided to ensured members
ZAMBIAN MODEL OF SOCIAL HEALTH PROTECTION SCHEME
Phase 1:
To cover 200,000 vulnerable households under the social cash transfer scheme (1,000,000 vulnerable people covered at inception) covered from inception
To cover 650,000 employees in the formal sector (private and public sector) through the existing systems (3.3 million people)
Implication is that 4.3 million Zambians i.e. 30% of population covered at inception
Phase 2:
Informal sector to be rolled in the second phase
This is a significant and important group (only 11% of workforce is in formal while the rest are in the informal)
1. The proposed Zambian social health insurance model is single pool, pro-poor program that ensures cross
subsidization amongst different population groups and protects beneficiaries from catastrophic expenses
2. It fits well in the social protection framework as it is part of the policies and programs designed to reduce
poverty and vulnerability by diminishing people's exposure to risks, and enhancing their capacity to manage
economic and social risks associated with sickness
The Zambian health sector is anchored on the WHO health systems framework
Health Resources for Health
Service Delivery
Health Care Financing
Infrastructure, Equipment &
Commodities
Health Management
Information System
Leadership and Governance
Improved Efficiency
Financial Risk Protection
Responsiveness
Improved Health (Level &
Equity)
Access Coverage
Quality Safety
System Building Blocks of the
Zambian Health System Outcomes/Goals
UHC IN THE ZAMBIAN CONTEXT…INITIATIVES
How to best balance
cost, quality, and access
in a manner that is both sustainable and
consistent
with social values and political goals?
• Removed User Fees at PHC level• Increased Govt. allocation to Health by
300% in last 5 years• Improved efficiency through resource
tracking & revised RAF• Improve supply chain mgt.
• Construction of 650 Health Posts
• Upgrade & Modernization of
Hospitals
• 160 Basic Life Support Ambulances,
5 Mini & 42 Advanced Life Support
• 9 Mobile Units
• Modernization of facilities to diagnose
and treat patients
• Training of more Health Workers (new
Medical school & TIs)
• Salaried CHW
• Improve supply chain mgt.
Delivering high quality Providing access
Responding to costs
UHC IN THE ZAMBIAN CONTEXT… OTHER INITIATIVES
Introduction of SHI
Draft SHI bill in place
Sensitization meetings on SHI with key stakeholders
Zambia Household Health Expenditure and Utilization Survey
Informal Sector Rapid Assessment
Mid Term Review of the National Health Strategic Plan
ZDHS surveys
SOCIAL HEALTH PROTECTION IN ZAMBIA AND UHC
(Equity, Quality & Protection From Financial Risk)
Health Financing Strategy
The health financing strategy Government is working on is designed to provide all people with access to
needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to
be effective; ensuring that the use of these services does not expose the user to financial hardship (SHI is
not a silver bullet for UHC but a component of a wider HCS)
Breath of Coverage
Inclusion of the informal sector, the poor & indigent is critical for Universal Health Coverage
Type of Service
It is not just about reaching everyone, services must be meaningful
Services must be holistic - from prevention, promotion to urgent medicals services.
CHALLENGES IN IMPLEMENTATION
Meeting expectations of the insured population in availability and quality of health services
Covering the informal population – registration and contribution collection
Developing mechanisms to cover near-poor and those not covered by SCT
Developing capacities and retaining human resources
Mobilizing financial resources for subsidies to the Vulnerable groups
Developing awareness on social health protection from insured population and employers
Reaching administration efficiency in a public institution
Current Landscape of Government Financing and Health Financing Options
Government Financial Allocation Ministry of Finance Zambia
GOVERNMENT RESOURCE
ALLOCATION
Ministry of Finance
OUTLINE OF PRESENTATION:
Determining the Resource Envelope
Sources of Government Revenue
Developing Broad Expenditure Allocations
Determining Intersectoral Allocations
Issues that Determine Resource Allocations; and
Prioritising of resources within MPSAs
Determining the Resource Envelope
First step in MTEF process requires maintenance of a consistent
Macroeconomic Framework (3 year period)
Macroeconomic Frameworks depicts:
changes of the economy as a whole
changes in the Monetary sector and provides the extent to which Government can
borrow from the system
external flows, including debt payments donor grants, exports and imports
the level of resources that are available for spending by the public sector
Determining Resources contd…..
changes in the Real sector i.e Output and prices
changes in the Fiscal Sector, including how much Government projects
collect in terms of revenues and how much government is projecting to
spend.
The Fiscal Framework indicates/projects the total resources that are
available for the Central Government Operations ( Expenditure) in the
3 year period
Sources of Government Revenue
Sources of the Revenue include the following:
Domestic Revenue
Tax and non-tax
Miscellaneous Revenues
Exceptional revenue etc
Foreign Grants
Grants (project & programme)
Financing
Domestic Borrowing
External ( Programme & Project loans)
Sources of Government Revenue
Developing Broad Expenditure Allocations
Once the total resources are estimated, including donor inflows, the next stage is to provide for:
Constitutional Expenditures, i.e. those expenditures for which government has a legal obligation. These include debt payments, pensions, transfers to local government, earmarked revenues for special funds.
Contractual commitments for the payment of personnel ( including pension entitlements that are due or will fall due)
Domestic Arrears (Debt servicing and amortization) and, in some cases, contracts for the delivery of goods and services that extend between budget periods
Agreements and accords with bilateral and multilateral agencies for the counterpart financing for projects and programs
Developing Broad Expenditure Allocations
Cont’d….
There are some broad expenditure policies that influence the allocation of
resources, including:
appropriate levels of staffing and structure of the civil service
wage policies and any planned salary increases
balance between personnel cost, recurrent costs and capital expenditures
policies on levels of donor flows, i.e. the degree of aid dependency
Fiscal Framework
Once the Resources Envelope and the Broad Expenditure categories
are established, the next step is to develop the Fiscal Framework.
The Fiscal Framework indicates the total resources that are available
for the Central Government Operations ( Expenditure) in the 3 year
period
Determining Inter-Sectoral Allocations
The basis for and processes of decisions on resource allocation between sectors and MPSAs’ is based on a combination of
Top down information on government priorities and policies
Bottom up requirements from each MPSA of the funds required to achieve the agreed government objectives and targets
Determining Inter-Sectoral Allocations
Macroeconomic Framework
Resource Envelope
Administration Economic and
Infrastructure
Social Sector Public Safety Sector
Constitutional Expenditures
Debt Payments, Pensions etc
Government Policies and Priorities
MPSA Policies and Priorities
Expenditure Requirements of priority
Services and Infrastructure
MPSA Ceilings
Government policy informs
MPSA policies
Scope of MPSA services and
infrastrucrure influenced by
policies
Costs of policies influences
priorities and allocation of
resources
Top DownBottom Up
Options presented to Cabinet on
a) Allocating additional resources, or
b) redefining policies and programmes to fit
within resources available
Issues that Determine the
Allocation of ResourcesThe decisions about resources allocation between and among
MPSAs’ needs to be based on a combination of the
following factors: Allocation of funds to achieve set Government objectives
An analysis of the issues within a sector and the constraints to achieving planned outcomes needs to guide resource allocations.
Clearly defined Sectoral linkages, such as the need for roads in the agriculture and tourism sector, so as to define the requirements for roads expenditures.
The role of government in the sector, i.e. whether government is:
a provider of services and infrastructure,
a facilitator of private sector development ,
a regulator of private sector activity; so as to determine the levels of resources required in a sector.
Issues that Determine the
Allocation of Resources
Facilitator vs provider:
For example; although agriculture and tourism are priority sectors for government, government’s role is mainly to facilitate and regulate private sector development. Therefore the resource requirements are not as high as if government were providing services in these sectors.
In the social sector of health, were the Government is the provider, the resource requirements are high.
Importance of prioritizing within MPSAs
MPSAs also need to prioritise within their own organisation to make use of limited resources
The factors that would guide the allocation of resources within an MPSA are the same as those at the national level, i.e. Those programmes that achieve government objectives with the least cost and within the resources
(both financial and human) available to the organisation
Based on the role of government for the particular programme, i.e if government is the main provider of a service then the expenditure requirements would be higher than if the government is mainly facilitating private sector growth
Whether there are options for involving the private sector and/or NGOs and communities in the delivery of services, as well as other options such as charging for services
2014-2015 Allocations to the Health Sector
2014 Allocations:
FUNCTION K’million Percentage of
Budget
Health 4,228.4 9.9
Drugs and Medical Supplies 738.7
Medical Infrastructure and Equipment 312.3
TOTAL BUDGET 42,682.0
2014-2015 Allocations to the Health Sector
2015 Allocations:
FUNCTION K’million Percentage of
Budget
Health 4,464.09 9.6
Drugs and Medical Supplies 753.52
Medical Infrastructure and Equipment 268.24
TOTAL BUDGET 46,666.56
Current Landscape of Government Financing and Health Financing Options
Health Financing Strategy and Social Health Insurance in Zambia
Ministry of Health Zambia
Advocacy Symposium for Scaling up Universal Health Coverage in
ECSA-Health Community
Health Financing and Universal Health Coverage in Zambia
Presented by
Mubita LuwabelwaDeputy Director (Planning & Budgeting) - MOH
Pamodzi Hotel, Lusaka - Zambia, 30 June – 1st July 2015
Some Key Policy Level Questions in the UHC Agenda
1. Where shall we be in tomorrow’s world?
2. What key lessons can today’s UHC agenda learn from history?
3. Is the “Trinitarian” representation of UHC achievable?
4. Should the “Health Sector Proper” crowd out other sectors (SDH) in financing the UHC agenda?
Some Global HighlightsKey variables for the UHC Community to reflect on
• Sub-Saharan Growth to remain at 5% per annum in 2013 (IMF, 2013)
• 6 of the fastest growing economies in the world in the past decade are in Sub-SaharanAfrica, (The Economist, May 2013)
• 1 billion people do not have access to health care; 100 million fall into poverty everyyear due to illness
• Sub-Saharan Africa is now the second fastest-growing region in the world, trailing onlyemerging Asia (IMF, 2013)
• Translating real GDP growth to quality of life & poverty reduction remains a challenge inZambia and the Sub region
• By 2050, almost one quarter (23%) of the working age population will be in Africa
• Four out of 10 most populated countries are in Africa, and the fertility rate in Africa iscomparably very high
• Sub-Saharan Africa has 11% of world population, 25% of the world burden of diseasebut only 3% of world’s HRH (WHO)
• 56.0 million people die everyday year (6,390 deaths per hour. 153,000 deaths per day4,590,000 per month)
• 146.0 million babies are born every year, (16,600 per hour, 400,000 every day, 12million every month
• Net increase of 250000 human beings a day, 90 million per year (1.4%) - We arecrowding 6,500 million people on the planet.
• Income distribution remains high (gini coefficient = 0.40 – over 0.52)
There is no shortage of growth in Africa(The Economist, May 2013)
Health Financing at a Global Level
Good NewsRegional Governments are increasingly spending more on health
(e.g. Malawi and Zambia)
Sadly, less money is still spent on each individual in the region
Bad NewsThe UHC Agenda in the ECSA region is still threatened by the dependency syndrome
There is some progress in financial protection in the region – more remains to be done
Zambia: Growth in Health Sector Budget 2010-2015
Source: Ministry of Health
Financing Sources
• The main financing sources are Government, CPs & Households
• Employers and other sources continue to play a minor role in health financing
On average•Government – 50%•Donors – 39% (mostly vertical programmes & off-budget)
•Households (OOPs) - 7%•Employers – 4% •NGOs - <1%
NoteOver 90% of operational funds are now by Government
General Revenue (Tax) is Main Source of funding with relatively low OOPs (preliminary)
Zambia: Total Health Expenditure by Function (preliminary)
• Curative - 54%
• Prevention or Public health programs -27%
• Health Administration & Insurance – <6%
• Health Care Related – 6%
• Other – 6%
Note
Rising administration costs need to be contained
.
0%
10%
20%
30%
40%
50%
60%
Series1
Zambia: Overall Health Expenditure
Note:• Overall increase in
expenditure on health
• Increased Government spending
• Declining overall expenditure by CPs (relative)
• However, CPs remain key funders of key vertical programmes such as Malaria, HIV/AIDS etc
Expenditure by Source
50%
4%7%
0%
39%Central Government
Employer funds
Households
NGOs
Rest of the World
Social Determinants of Health and UHC
Is Increased financing of the health sector alone at the expense of other
sectors enough to reach UHC?
Collaboration between Ministries responsible for Health and other
sectors is critical if UHH is to be achieved
Key Role of Social Determinants of Health
Category Determinant Details Sphere
Cultural Status of woman Elements of patriarchy ‘Cultural
Propriety’
informal
Social Age and sex
Socioeconomic Household resources Educational level
Maternal occupation
Marital status
Economic status
Economic Costs of care Treatment
Travel Time
Physical
infrastructure
Type and severity of illness
Geographical Distance and physical access
SDH: Factors Influencing Health Services.
ENVIROMENTAL POPULATION CHARECTERISTICS HEALTH OUTCOMES
BEHAVIOR
Health Care
System
External
Environment
Predisposing Enabling Need
Characteristics Resources .
Personal
Health
Practices
Use of
Health
Services
Perceived
Health Status
Evaluated
Health Status
Consumer
Satisfaction
Source: Anderson, RM (1995): Revisiting the behavioral model and access to medical care: does
it matter? Journal of Health and Social Behavior, 36:1-10
Where are we on the match towards UHC as a region?
• There is need to have a proper analysis on the dimensions of coverage that reflect a set of
policy choices about benefits in reforming health financing systems towards universal coverage
in the ECSA region
1) Population: Who is covered in ECSA-HC?• The large informal sector in the region threatens coverage of population -through pre-payment schemes
• Free primary health care is also not sufficient
• Access remains a challenge for more people due to costs, distance etc.
• The private sector still largely remains to be tapped to fill the gap
1) Services: Which Services are Covered in ECSA-HC?• Low HRH still threatens quality of care (3% of Global HRH and yet 25% of Global disease burden - Africa)
• Access to tertiary level care remains a big challenge
• Technology such as telemedicine is an opportunity
• Treatment abroad is very expensive and inequitable
1) Direct Costs: Proportion of the costs Covered in ECSA-HC?• Population covered by prepayment system remain low
• Transport due to distance travelled & food for the patient and care giver remain the highest costs (ZHHEUS and KHHEUS)
• Charges for diagnosis still exorbitant and a hindrance for better health
Key UHC Considerations - Past and Present
There is no need to re-invent the wheel for UHC for ECSA-HC member states
Free lessons are abundant to learn from
Modern day achievements from countries such as Thailand, including regional pioneers such as Tanzania, Ghana
However, there is need to contextualize the design of UHC programs to country and regional levels if UHC is to be achieved
Is there need to re-invent the Wheel for UHC for ECSA – Free Lessons are there
The Beveridge Model (National Health Model)
Named after William Beveridge, the daring social reformer who designed Britain’s NHS.
Features• Health care is provided and
financed by the government through tax payments
• Most hospitals and clinics are owned by the government;
• Some doctors are government employees, but there are also private doctors who collect their fees from the govt.
• These systems tend to have low costs per capita
• Examples: Britain, Spain, Scandinavia New Zealand. Hong Kong still; Cuba
The Bismarck Model (Social Insurance Model)Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Features• It uses an insurance system
where a fund is usually financed jointly by employers and employees through payroll deduction.
• It covers everybody, and is not for profit.
• Doctors and hospitals tend to be private in Bismarck countries
• Tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.
• Examples: Germany, France, Belgium, the Netherlands, Japan, Switzerland, In Latin America
National Health Insurance Model
System has elements of both Beveridge and Bismarck.
Features
• Uses private-sector providers,but payment comes from agovernment-run insuranceprogram that every citizenpays into.
• No financial motive to denyclaims and no profit
• It’s a universal insurancescheme & tends to be cheaperand much simpleradministratively
• National Health Insuranceplans also control costs bylimiting the medical servicesthey will pay for, or by makingpatients wait to be treated.
• Examples: Canada, Taiwan,South KoreaNote
1. The two main models are the Beveridge and Bismarck Models. The NHIM is a combination of the two
2. There are other models such as the private insurance model, out of pocket model but these are generally variants of the 2 main models and this includes the NHI model above.
What has Zambia Learned from the 3 Dimensions of UHC
• Choices need to be made about proceeding along each of the three dimensions, in many combinations, in a way that best fits Zambia’s objectives as well as the financial, organizational and political context in Zambia.
• Extending the coverage from pooled funds along the three dimensions calls for health financing reforms and actions leading to:
1) An increase of available funds for health2) An increase in the share of these funds collected through prepayment and the arrangements for pooling them3) Efficiency gains4) Upholding and increasing the quality of health services.
Source: Adapted by MOH from WHO Principles
Why SHI Scheme when there is “Free” primary health care?
Despite the free primary health care policy, Zambian households still have topay for their health expenses:
• At secondary and tertiary levels• At primary level: for drugs, diagnostic tests and others services that may
not be available at the government facilities• In the private sector
“Free” health care for the citizens are limited to what the Government canafford.
Costs incurring at the point of service are the major financial barrier for theZambian citizens to access the right care at the right moment.
SHI Program is not a silver bullet for UHC in Zambia but sits well in the widerhealth financing reform agenda
Zambia is in the Process of Implementing a SHI Scheme in Zambia BUT……..
Zambia’s Policy Emphasis on the Wider Health Financing Agenda for UHC
Coverage of Financing for health: The Financing for Health program should not be for
the privileged, select few or the elite but for all i.e. the “Zambia National Health Service”;
Cash Flow: The design of the health financing strategy, including the SHI program must
be designed to withstand cash flow fluctuations in the sector so that there is no
interruptions in the flow of essential services to the people;
Drug Supply: The essential drug list must be appropriately designed to capture the
necessary drugs and this essential drug list must always be available;
Result Based Financing: The health financing must have an incentive based
financing/Result Based Financing mechanism;
The Poor and Vulnerable: The welfare of the poor and vulnerable as well as special
population groups such as the elderly and differently abled must be well secured in the
program.
Source: Dr. J. Kasonde, Hon Minister of Health, MP, April 2014
Zambian Model: National Social Health Insurance Scheme
Phase 1:
• To cover 200,000 vulnerable households under the social cash transfer scheme (1,000,000 vulnerable people covered from inception)
• To cover 650,000 employees in the formal sector (private and public sector) through the existing systems (3.3 million people) Implication is that 4.3 million Zambians i.e. 30% of population covered at inception
Phase 2:
• Informal sector to be rolled in the second phase
• This is a significant and important group (only 11% of workforce is in formal while the rest are in the informal)
1. The proposed Zambian social health insurance model is single pool, pro-poor program thatensures cross subsidization amongst different population groups and protects beneficiariesfrom catastrophic expenses
2. It fits well in the social protection framework as it is part of the policies and programsdesigned to reduce poverty and vulnerability by diminishing people's exposure to risks, andenhancing their capacity to manage economic and social risks associated with sickness
3. SHI is aimed at ensuring that:• All Zambians, are covered in a phased approached, and irrespective of their socioeconomic status
have access to quality health care• Quality health services are delivered equitably• The covered population does not pay for accessing health services at point of use• The covered population has financial risk protection against catastrophic health expenditure
What Progress has been made so far
• Legal framework: SHI included in key policy documents, SHI Bill ready, consultations process with key stakeholders on-going
• Organizational design set-up
• Major components of the scheme designed
• Discussion with MoLSS, MoJ, Cabinet Office & other stakeholders to ensure alignment with Pension reform on-going
• On going design of collection contribution mechanisms
• Capacity building on Social Protection and Social Health Insurance started
• Informal Sector Rapid Assessment (April 2014)
• Updated Actuarial Assessment (2013)
• Zambia Health Expenditure and Utilization Survey (Report Due in July 2014)
• Zambia Demographic Health Survey (Report Ready)
Other Key Issues in preparation for the UHC Agenda
Health Financing Strategy
A wider Health Financing Strategy is being
worked on
SHI is an important but not exclusive feature of
the strategy
Infrastructure development and Medical
Equipment
Construction of 650 Health Posts
Construction of 30 District Hospitals with an
additional 8 to be added this year
Upgrade and Modernisation of Hospitals
Building Flagship Hospitals
160 Basic Life Support Ambulances,
5 Mini & 42 Advanced Life Support
9 Mobile Units
Legislative Reforms
SHI Bill
NHS Act
Hospital Reimbursement Reform
National Health Facility Standards (HPCZ)
PHC Reengineering
Improving Supply Chain Management
E-Health Strategy
Improving Hospital and District Management and Governance
Review Health Package, Standard and EML
Establishment of Health Research Authority
Health Care financing strategy
Population registration (with Home Affairs)
Human Resources Management
New Medical Schools
National Training Institution
Salaried Community Health Assistants
National Training Operational Plan
HRH Strategy for Health
Challenges Foreseen in Implementation
• Meeting expectations of the insured population in availability and quality of health services
• Covering the informal population – registration and contribution collection
• Developing mechanisms to cover near-poor and those not covered by SCT
• Developing capacities and retaining human resources
• Mobilizing financial resources for subsidies to the Vulnerable groups
• Developing awareness on social health protection from insured population and employers
• Reaching administration efficiency in a public institution
Conclusions
• It’s not “How much” we are spending, but “HOW we spend”
• Other sectors are critical (Social Determinants of Health)
• Technology/telemedicine has to play a key role
• There is enough robust growth to gunner change BUT equity is important
• Increased younger age population will “demand less health care” –(except the under 5 age group) – (dome shaped demand function)
• UHC as a path and not a goal has to be defined
Conclusions
Countries must aim to reach BUT:
Services must be meaningful
Continuum of care must be assured i.e. from prevention, promotion, rehabilitative and urgent medicals services
Services must be prioritised and expanded e.g. maternal and child health services must be prioritised and then plan to expand
Research and Emerging gaps
Research and existing evidence University of Zambia
Research and Evidence – Universal Access to
Health Care
Bona M Chitah,
Department of Economics,
The University of Zambia
BM Chitah - UHC and Research Gaps 90
Interpretation or Implications of Conceptual Foundation
• “UHC establishes what is to be achieved but says little on how to
get there, and even though there may be a few features
commonly associated to UHC and a few paths that do not seem
to lead to UHC, it does not fully clarify what can be considered
a UHC effort.”
BM Chitah - UHC and Research Gaps 91
Concepts (WHO/EIP/MHI)
• Health supply side terms
– Availability
– Affordability
• Health demand side terms
– Utilisation
– Acceptability
Access =
how much a population can reach health
services
Coverage =
the share of a population eligible (beneficiaries) for a set of
interventions
Patients and population
BM Chitah - UHC and Research Gaps 92
Historical context – Models of Primary Health Care
Comprehensive Selective Medical model
View of health Positive wellbeing Absence of disease Absence of Disease
Locus of control over health Communities and individuals Health professionals Medical practitioners
Major focus Health through equity and
community participation
Health through medical
interventions
Disease eradication through
medical interventions
Health care providers Multidisciplinary teams Doctors plus other health
professionals
Doctors
Strategies for health Multi-sectoral collaboration Medical interventions Medical interventions
Rogers W. & Veale, B. (2000).
Historical Context
• Comprehensive Primary Care and Health for All
• Alma – Ata (1978)
• PHC – Now more than ever (2009)
• Criticisms – failures – successes?
BM Chitah - UHC and Research Gaps 94
Factors and Rationale for UHC
• Health status – slow progress in differences between different
geographical regions
• Growing inequities intra-country and inter-country both in terms
of health outcomes and heath care resources
• Increasing financial risk and health induced impoverishment –
financially induced and poor – health – productivity
consequences
• Poor quality health care
BM Chitah - UHC and Research Gaps 95
Methodology
• Purposeful
• Selected review (systematic)
• Search terms: “universal access coverage” filtered by “evidence”
• Limited number of studies evaluated – requires further work
BM Chitah - UHC and Research Gaps 96
UHC – Definitional Issues
• Access to provision of and utilisation of health care services
• Where needed when needed,
• Required quality and standard
• Without unnecessary and un-affordable barriers• Summary: Services accessed by all, meeting health care need of population,
interacting and leading to,
• improved population health
• Access to health care
• Financial risk protection
• i.e. through better outcomes, outputs, processes, systems and inputs
BM Chitah - UHC and Research Gaps 97
Policy and Research - Concept
• Health policies - purposeful and deliberate actions through
which efforts are made to strengthen health systems in order to
promote strengthen health systems whilst also showing how
population health.
• Its multi-discilinary disciplinary research field, distinguished by
the issues and questions addressed through the research rather
than by a particular disciplinary base or set of methods;
BM Chitah - UHC and Research Gaps 98
Health Systems Research (and Policy)
• Includes qualitative and quantitative investigations and inquiries
into determining and analysing data and information on health
services; revention; promotion of health in general;
• Includes global and international; national and sub-national
issues over health systems
• How policies are developed and implemented and the influence
that policy actors have over policy outcomes – it addresses the
politics of health systems and health system strengthening;
BM Chitah - UHC and Research Gaps 99
Translation of Concepts, Policy, Strategies and Implementation into
Basis For Evidence
• Health system: people, institutions, resources, policies and
activities serving the primary function of promoting and/or
maintaining good health while promoting availability of quality
care and protecting population against financial cost of care
• Six core factors: Leadership and Governance; Service Delivery;
Health Human Resources; Health Information Systems; Medical
Products, Vaccines and Technologies; Health Care Financing
BM Chitah - UHC and Research Gaps 100
Inter-Relationships and Knowledge Gaps
• Health System and links towards improving and maintaining:
• Utilisation;
• Health Care Need and
• Quality of services provided efficiently to generate desirable outcome, responsiveness and financial protection
BM Chitah - UHC and Research Gaps 101
Leadership; Governance
Information
Medical products; technologies
Service delivery
Human Resources in Health
Financing – Collection, Pooling, Purchasing
Utilisation
Health Care Need
Quality of Service Delivery
Efficiency – efficacy, CEA
Health Outcome –level and equity
Responsiveness of service provision
Financial Protection
BM Chitah - UHC and Research Gaps 102
Health Systems Health Policy and Environment
Public Health Linkages HardwareStructure
TechnologyResourcing
Organisation
SoftwareValues; Norms; EthicsActors; Relationships
System Functioning - Policies,
Strategies, Activities, Evidence
and Change
Content &InstrumentsActors, Power& PoliticsInstitutions, Interests
GLOBAL AND NATIONAL INTERESTSBM Chitah - UHC and Research Gaps 103
Health Systems and UHC
• Design and functioning of health system- evidence and areas required
• Affordability of financing models/strategies
• Determination of health need – extent, priorities, interventions/services
• Access
• Prioritisation of:– Socio – economic sub-populations
– Benefits packages; interventions and services
BM Chitah - UHC and Research Gaps 104
Health Systems: Governance and Organisation
• Resource mobilisation – collection, pooling, purchasing
• Design of health systems and health outcomes – determining
causal linkages and understanding how to improve efficiency in
process
BM Chitah - UHC and Research Gaps 105
Governance and Organisation
Design and effects of UHC Models
• Beveridge Model – general revenue funding model (tax based); public
provision of services
• Bismarck Model – labour market based and dependant extensively on
labour market segmentation and payroll taxes by consequence
• Distinguishing features:
– Arrangements of benefits
– Organisation of providers
BM Chitah - UHC and Research Gaps 106
• Purchasing and payment modes for services
• Hybrid of Beveridge and Bismarkian?
• Revenue Collection – Pooling and Prepayment mechanisms
dominant – Can prepayment and pooling, achieve greater
impact than alternatives
• Coverage of socio – income groups – who are beneficiaries
BM Chitah - UHC and Research Gaps 107
• What extent are services accessed and distributed across
population groups
• Costs, institutional framework and efficiency
BM Chitah - UHC and Research Gaps 108
Access and Utilisation…
• Access in health care may be defined as a measure of potential and actual entry for a given population into the health system. Its determined by the interaction of the characteristics of the health care system and the characteristics of the potential user (Khan and Bhardwaj 1994).
• Five dimensions of access: availability, accessibility, accommodation, affordability, and acceptability.
• improving affordability will not necessarily improve access and utilization if the other dimensions have not also been addressed
• Financial protection; health status
BM Chitah - UHC and Research Gaps 109
Note…Difficulty with identifying UHC attribution
• Establishing the causal effect of an intervention requires mimicking a counterfactual situation (what would have happened in the absence of the intervention?) to rule out other factors that may simultaneously affect the outcome of interest.
• Counterfactual is impossible to observe in reality, it is usually estimated by using comparison groups. Therefore, an impact evaluation will typically analyze a group composed of those who participate in (or are affected by) the intervention being evaluated (also called the treatment group) and at least one comparison group (also called the control group).
BM Chitah - UHC and Research Gaps 110
• Endonegeity: Controlling for observed and unobserved differences when
evaluating the impact of UHC is key for an accurate assessment of the
cause and effect relationship
• Bidirectional causality between health status and UHC schemes:
• The bidirectional causal link between health status and UHC will make it difficult to identify the impact of UHC on health status unless either coverage is completely random or the data on health status prior to the intervention are available to correct the problem.
BM Chitah - UHC and Research Gaps 111
• The evidence of the impact of UHC schemes will probably be available for only some
schemes, particularly those that are still in early transition periods. Furthermore, there will
probably be no causal evidence of the impact of UHC systems in certain countries (for
example, little or no information exists on the impact of Chile’s social security system or
for certain types of UHC systems such as those that automatically entitle the whole
population to the benefits without any formal enrolment procedure, as was done in
Sweden or Spain)
BM Chitah - UHC and Research Gaps 112
Access, health status, and financial protection depend on much more than UHC.
• When evaluating the impact of UHC schemes on access and
financial protection, it is necessary to have a thorough
understanding of the many other determinants of each of these
performance dimensions. Results may be interpreted erroneously
when ignoring them.
BM Chitah - UHC and Research Gaps 113
UHC and Health Status Outcomes
• When selecting health status variables to measure the impact of UHC
schemes, care should be taken to ensure that a clear relationship exists
between access to health care and the health status variables being
considered, Levy et al. (2001)
Link Between Interventions and Outcomes
• The program’s theory of change should be explicitly stated when researching
UHC schemes, and the outcomes should be carefully chosen according to that
theory of change. Programs should not be evaluated based on outcomes
that are not affected by the intervention.
BM Chitah - UHC and Research Gaps 114
Methods
• Study design. The key weakness of the evidence is the flaw of many
study designs; standard regression or descriptive statistics only to explore
causal relations.
• No or very few randomised studies
• There is still a long way to go to have an extensive and robust evidence
base on the impact of UHC-like interventions
BM Chitah - UHC and Research Gaps 115
Research
• Expanding Coverage
• Which models work better (efficiency, equity, coverage)
• What is ideal or critical institutional framework and systems
required to ensure organisational, stewardship, support and
technical guidance and oversight exist
• For instance what is capacity to set priorities for benefits
package – services to be provided
BM Chitah - UHC and Research Gaps 116
Ethics of public health practice
• What and which services shall be provided and why
• What is the basis of doing what we do and is this affected or
does it affect how resources are distributed, access is shaped
and determined and services are provided? e.g. does an
objective utilitarian position matter from a positive egalitarian
and what are the implications
BM Chitah - UHC and Research Gaps 117
Health Care Financing
• Fee – for service = cost escalation => cost containment measures but
these negatively affect coverage and financial risk protection
• Equity
• Resource mobilisation (vertical versus horizontal equity), macro
economic growth and capacity, feasibility – issues of actors, political
positions
• Risk pooling
• Efficiency (cost – effectiveness)
• Purchasing
BM Chitah - UHC and Research Gaps 118
Pooling and Purchasing (Redistributive functions)
• Experiences of cross – subsidisation = rich and poor; (low risk) young and
old (high risk)
• Incrementalist approach – fragmentation of pooled resources and
management of pools
• Undeveloped formal labour market; size and capacity of labour market
• Consideration of “special” groups as incremental strategy is adoped –
equity and access consequences – political and ethical considerations
BM Chitah - UHC and Research Gaps 119
Human Resources for Health (health workforce)
• Access – infrastructure, technology, medicines and medical
supplies, ,governance = human resources for health to turn
processes, inputs into outcomes together with the households
• Balance distribution of health staff
• Provide incentives (financial and non-financial)
• Private and Public sector conflict
BM Chitah - UHC and Research Gaps 120
Areas where some results known
• A majority studies that analyse impact of UHC schemes on access and
that belong to the two top quartiles find favourable and statistically
significant impact of UHC schemes. This suggests that sufficient evidence
exists indicating that UHC schemes do improve access.
• Changing impact across outcome variables. Wagstaff and Yu (2007)
find positive impacts of UHC scheme on use of specific services (hepatitis
B immunization and the incidence of nontesting of suspected TB patients),
but no impact on more general measures of outpatient and inpatient
utilization.
BM Chitah - UHC and Research Gaps 121
• the general health insurance (GHI) program in Ecuador “is strongly
associated with the use of curative health care, but does not seem to
influence the use of preventive care”
• Substitution or increase in utilization? in some cases, UHC schemes
have an impact on the type of care used—changing from self-
medication or alternative medicine to formal care. In some cases,
UHC schemes have an impact on the type of provider chosen rather
than on utilization levels
BM Chitah - UHC and Research Gaps 122
• Impact on access only by means of improved affordability? UHC
schemes focusing on the reduction of financial barriers to access are not
expected to improve other dimensions of access beyond affordability.
(Can there be externalities)
BM Chitah - UHC and Research Gaps 123
Financial Risk Protection
• Overall impact. The impact of UHC schemes on financial protection is less
often studied than their impact on access;
• Results indicate that UHC schemes may reduce out-of-pocket
expenditures, and sometimes prevent catastrophic expenditures and
impoverishment
• In some cases, the results are mixed; In general, much more research is
needed in this field since most studies rely heavily only on conventional
measures of financial protection (out-of-pocket/catastrophic expenditures
and impoverishment).
BM Chitah - UHC and Research Gaps 124
What measures do not do….
• Fail to capture cost barriers to access - categorize those who cannot afford care as spending little or nothing on care assuming them (erroneously) as financially protected;
• Do not include other health-seeking related costs beyond direct payments, such as transportation costs
• Do not capture other strategies to cope with costs of illness such as reduced household consumption of other goods and services or increasing debt to finance health expenses;
• Do not include indirect costs such as income loss due to illness
BM Chitah - UHC and Research Gaps 125
• The link between financial protection and utilization- financial
protection is meant to be achieved primarily by reducing payments at the
point of service. The price subsidy is expected to—increase demand and
improve access to health services
• outpatient and inpatient care- greater benefits on inpatient care.
BM Chitah - UHC and Research Gaps 126
Health Status
• A majority of inconclusive studies. Several studies cannot find
conclusive evidence on the impact of health insurance when they
use health status measures available
• The evidence on the marginal impact of individual design features and the usefulness of impact evaluation evidence to date for policy guidance. Little known on the marginal contribution of the impact of individual design features of the UHC scheme
BM Chitah - UHC and Research Gaps 127
Other
• Balance – Supply side and demand side synchronisation and results
• Purchaser – Provide Split (Performance based financing)
• Is scheme welfare increasing – do the gains outweigh the inefficient moral
hazard spending.
BM Chitah - UHC and Research Gaps 128
Research and Emerging gaps
Defining Zambia’s Proposed SHI Package National Health Insurance Coordination Unit
SERVICE PROVISION UNDER THE PROPOSED NATIONAL SOCIAL
HEALTH INSURANCE SCHEME
DR. MPUMA KAMANGA
NATIONAL HEALTH INSURANCE CORDINATOR
MINISTRY OF HEALTH
130
30th June, 2015
ADVOCACY SYMPOSIUM ON UNIVERSAL HEALTH COVERAGE
Theme: “ Where are we & where are we headed?”
OUTLINE
Background
Context of reforms
Universal Health Coverage
Designing the Benefit Package
National Social Health Insurance Scheme- Main Reform features
BACKGROUND
Zambia is in the advanced process of implementing a National Social Health Insurance Scheme (NSHI) as a
mechanism to complement progress towards UHC
Currently only 3.9% of the population has any form of health insurance coverage
SHI is aimed at ensuring that:
All Zambians, are covered in a phased approached, and irrespective of their socioeconomic status have access to
quality health care
Quality health services are delivered equitably
The covered population does not pay for accessing health services at point of use
The covered population has financial risk protection against catastrophic health expenditure
THE THREE DIMENSIONS OF UHC
Universal health coverage (UHC) is defined as all people receiving quality health services that meet their needs without
being exposed to financial hardship in paying for the services
HOW TO MOVE IN THE DIRECTION TO UHC?
Expand services covered
– Which services?
Include more people into coverage
– Where to start and who will be eligible?
Reduce out-of-pocket payments by patients
– How to pre-pay more into a pool?
THREE-PART STRATEGY
Categorize services into priority classes. Relevant criteria include those related to cost-
effectiveness, priority to the worse off, and financial risk protection.
First expand coverage for high-priority services to everyone. This includes eliminating out-of-
pocket payments while increasing mandatory, progressive prepayment with pooling of funds.
While doing so, ensure that disadvantaged groups are not left behind. These will often include low-
income groups and rural populations.
SERVICE SELECTION CRITERIA
Careful selection of services is crucial for fair progressive realization of UHC
– Cost-effectiveness – Prioritizing services in order of their cost-effectiveness will provide the
largest possible sum of health benefits for a given budget.
– fairness recommends priority to services benefiting the worse off.
– financial risk protection – Financial risk protection is a key rationale for pursuing UHC
DESIGNING THE BENEFIT PACKAGE
Defined list of conditions funded through scheme unless on exclusion list.
Standard treatment guidelines for defined list of conditions/ common conditions.
Guidelines should define disease severity and the levels at which this should be managed.
Medicines should be linked to this clinical guideline – EML
SELECTION OF BENEFITS
Burden of Disease
Availability of services
Cost-Effectiveness
Safety
Quality
Appropriateness
Financial Protection
Comprehensive package across all levels
MATCHED BY
Strong emphasis on PHC, including prevention and health promotion (vs hospicentrism )
Prioritisation of services
Clinical guidelines, EDL, technology assessment
Gate-keeping
Strong referral systems
Need to manage progressive realisation of this package
Need to resist political pressure for excessive hospital care
WHICH SERVICES?
The public sector is the foundation for National Social Health Insurance Scheme
PROVIDED THAT
Strengthened :
Infrastructure & Equipment
Human resources (especially rural recruitment and retention)
High quality information system and ICT
Improved access, quality and efficiency
WHICH PROVIDERS? (1)
Private sector plays an important role (esp. GPs, private clinics, hospitals, pharmacies)
PROVIDED THAT
Single payer (risk pooling, purchasing power, comprehensive planning)
Price regulation
Active purchasing
Provide equivalent services
WHICH PROVIDERS? (2)
‘Incentivize health not services’
Reward good performance
Fee-for-service should not be the main mechanism
Capitation payments for PHC (plus some fee-for-service to incentivize prevention and
promotion?)
Global budgets for hospitals -> case-based payments (within global budget)
WHICH REIMBURSEMENT MECHANISMS?
NATIONAL SOCIAL HEALTH INSURANCE
VISION
Establish a High Quality & Efficient National Social Health Insurance Scheme:
Covering the whole population in a phased manner according to a defined time frame
Allowing both public and private health care providers from different health sectors to contribute in services
provision, based on quality & financial efficiency
Comprehensive Benefit package
Based on payer / provider split
Financially sustainable and administratively efficient
POLICY
The Rationale and need for a National SHI Scheme has been included in;
National Health policy 2012
Revised Sixth National Development Plan (SNDP)
National Health Strategic Plan (NHSP) 2011-2016
National Social Security policy and Implementation plan 2014
GOALS
1. To Achieve Universal Access to Quality health Care
2. To Improve the Quality of Service Delivery (Clean, Caring, Competent)
3. To Increase Resource Envelope, efficiency and ensure financial Sustainability
4. To provide financial protection from improvishment and paying for services at time of illness
MAIN HEALTH REFORM
147
Creation of a single Fund that is publicly owned and administered to:
Pool collected revenue derived mainly from general taxes and supplemented by mandatory earmarked payroll-linked contributions :
Strategically purchase personal quality health services from contracted public and private providers based on a specified service entitlement on behalf of the entire population
ALIGNMENT OF POOLING AND PURCHASING
FUNCTIONS
148
There will be one single institution that will pool funds and risks and purchase
services(Purchaser-Provider split)
Requires Legislative reforms through enactment of a bill and subsidiary statutory instruments
Single Fund/ Purchaser will contract with public and private providers
Standardized contracts for the various services (levels of care)
ALIGNMENT OF POOLING AND PURCHASING
FUNCTIONS
149
Accreditation requirements for all providers to be contracted
Certify for quality norms and standards
Accredits for performance
Post accreditation, quality monitoring
Reimbursement strategies to deploy standardized tools:
linking payments to performance and quality targets
capitation
Case-mix global budgets to DRG’s
Governance and Management Reforms in Public Sector facilities
(Decentralization, accountability and autonomy)
KEY FEATURES OF THE NATIONAL SOCIAL HEALTH
INSURANCE SCHEME
PROPOSED FRAMEWORK FOR ZAMBIA
SHI to cover all Zambians, adopting a 3 phase approach:
1. Very poor (100% GRZ for those receiving Social Cash transfers ) and Civil servants &
Public Workers
2. Private formal workers
3. The non poor informal population
WHO ARE THE BENEFICIARIES?
The registration is household based
This includes:
The contributing member
One spouse
All children below 18 – biological and adopted
Another 4 dependents
A household is defined as a person or a group of persons, related or unrelated, who live together and share common cooking
and eating arrangements.
POPULATION REGISTRATION
Members will be provided with a card to facilitate identification, eligibility verification at service provider level and
access to insured services
The cards will have unique and smart identification features (e.g. Unique ID numbers, Biometric capability will be
considered)
Benefits will be portable in cases of emergency, transfers, referrals, and migrant labour throughout the country in
accredited facilities.
NSHI cards for all population segments will be the same
avoid the stigmatisation of subsided households
WHO WILL MANAGE THE SCHEME?
The Scheme will be managed by an semi-independent body created through enactment of the Bill
Single Funder, publicly administered and separate from Providers
Close collaboration with regulatory bodies to enforce quality standards
Principle role: register members, issue membership cards receive funds, pool and purchase and contract quality
services on behalf of members
The scheme will not manage any health facility directly
Scheme will be publicly administered as a single purchaser with sub-national offices to negotiate and contract
accredited health providers (public and private)
Control measures will be put in place to ensure compliance with contribution collection and costs control (such as
provider payment mechanisms)
Administrative costs are to be limited to 10% of the total expenditures in the medium term
HOW WILL THE SCHEME IMPROVE THE QUALITY OF HEALTH SERVICES?
Specific mechanisms are considered to link payment to the providers to improved quality of care:
Accreditation,
Clinical audits,
Reporting requirements,
Performance based payment,
Guidelines on utilization of contribution revenue at provider level – to ensure the majority contribution
revenue will go to quality improvement.
Contracting mechanisms will bind accredited providers to the agreed quality mechanisms
Increased Competition between providers as Insured will have choice
HOW WILL THE SCHEME IMPROVE THE QUALITY OF HEALTH
SERVICES?
Set-up of a Complaint committee is proposed in the Bill (+ Ombudsman)
The payment of contribution will also give the patient a stronger voice to complain if not satisfied with the quality of health care.
provide initial investment for health care infrastructure and equipment (both public and private providers)-e.g. in the form of loans
SHI will bring ADDITIONAL financial resources to the Health sector.
The SHI contribution revenue will NOT replace the existing Government allocation to the health sector
WHAT IS THE BENEFIT PACKAGE?
COMPREHENSIVE BENEFIT PACKAGE:
Primary, Secondary, Tertiary Levels and specialized health care
Promotive, Preventive, Curative and Rehabilitative care
Consultations
Essential Medicines (including at Accredited Pharmacies and Chemists)
In-Patient & Out-Patients services,
Surgeries,
Diagnostic services & Screening Tests (Labs, X-Ray, CT Scan, MRI),
Oncology Treatment (Cancer Disease)
Pediatrics, Maternity care,
Physiotherapy, dental services, Vision care,
Annual physical check-ups, Immunizations
Flying Doctor service
Ambulance and Referral Services
Mobile Services
WHAT IS NOT IN THE BENEFIT PACKAGE? - EXCLUSION
Cosmetic surgery and aesthetic treatments and associated costs
Medicines not registered with the Zambia Medicines Regulatory Authority (ZAMRA)
Trans-sexual surgery
Treatment of infertility and artificial insemination
Spectacles and artificial lenses (except if medically required)
Experimental Treatment
Treatment of occupational accidents and illness – to be covered by Workmen’s Compensation Fund
Overseas health care services for medically necessary diagnoses and treatments.
Mortal remains repatriation
THE ZAMBIAN ENVISAGED MODEL OF NATIONAL SOCIAL HEALTH INSURANCE-
SUMMARY
Mandatory Enrolment
For all citizens and legal residents
No financial barriers at point of access of care
Single Payer Payment System
NSHI will be the only legitimate insurer of NSHI
benefits
Contracted service Providers paid on negotiated
reference price list
National Administration of the Scheme
Administered by independent agency through
enactment of legislation
Contributions into the NSHI Scheme
Employers and Employees
Self employed
Vulnerable covered by GRZ subsidies
Benefits
Comprehensive Benefit package has been defined
accredited Public and private providers will be
contracted
Cover will be for contributing member, spouse, all
children below 18yrs and 4 other dependents
Thank you