International Health Financing Policies

1. International Health Financing Policies J.-P. Unger Public sector health care unit Institute of Tropical Medicine, Antwerp, Belgium A presentation to Medicus Mundi Spain June, 2013

2. Plan • International health financing policies in LIC • International health financing policies in MIC • Alternative options

3. 1. International policies onhealth care delivery and financing in LIC

4. Alleged objectives ofinternational health policy (MDGs) • Reduce mortality by AIDS, TB, malaria • Reduce maternal and child mortality • Avoid communicable diseases spilling over in HIC

5. International health policy forgotten objectives • Improve equity in access to care • Reduce adult mortality • Reduce morbidity and suffering in children and adults • Control biological and social determinants of illness • Limit spread of resistance to drugs • Control health expenditure

7. Failure to reach (the quite limited) MDGs and even to progress in LIC • ± 50% of PLWHA needing treatment were receiving the medicines in 2009 (36% with new guidelines), far from the 100% aimed at in 2010 • TB prevalence in Africa: 1990-2007: +47% • Health care expenditure remains 1st cause of falling into poverty

8. Avoidable mortality and suffering • 11 million avoidable deaths attributable to communicable diseases yearly • ± 10 million avoidable deaths due to chronic diseases yearly • Generalised torture – avoidable suffering in LMIC by lack of access to care and drugs (a human right?)

9. Inefficiency of international aid • More than 120 disease control programs expandedbetween • Washington, Brussels and Geneva • LMIC capitals, towns and villages of LIC (with VHW) • The biggestevercreatedbureaucracy

10. European Parliament Total annual resources needed for AIDS under disease-specific organisation pattern Funding gap

11. Why this failure to control diseases? A negative feed back loop • for success, disease control programmes need patients consulting for various symptoms. They represent a pool of users that disease control programmes need for early case detection and sufficient coverage. Can malaria be controlled where basic health services are not used? Tropical Medicine and International Health, 2006; 11(3):314-322 • neoliberal policies allocate patients to private sector and disease control to public Letter. Public health implications of world trade negotiations. Lancet, 2004, 363: 83 3. while disease control programs limit access to care in public services e.g. polarizing them according to their interests 2003. A code of best practice for disease control programmes to avoid damaging health care services in developing countriesInt J Health Planning and Management 2003, 18: S27-S39

12. Why has access to health care been left out of international health policies in LICs? • Not because costs: costs of a few disease control programmes in DCs = costs of family medicine encompassing the same programmes Selective Primary Health Care: a critical review of Methods and Results. Soc. Sci. Med. 1986; 22, 1001-1013 • Because no subsided competition with the private sector is tolerated where there is a demand.

13. The international policy undermine LIC health systems Segmentation and fragmentation of systems • No more first line individual health care delivery • Proliferation of disease specific programs (52 in Congo)

14. The international policy undermined health systems in LIC • Limited responsiveness of health systems to respond to users demand and to host disease control programs • Community participation and support vanished • Poor status of public services professionals • Internal brain drain (LIC++) 2009. International health policy and stagnating maternal mortality: is there a causal link? Reprod Health Matters, 17,33: 91-104

15. Overall impact on health care • 1990: almost 50% fail to provide adequate access to care for their citizens in LIC and MIC UNDP. Department of Economic and Social Affairs, Population Division, United Nations, New York. ST/ESA/SER.R/151, 2000 • access to care particularly difficult in China, former Soviet Union, Africa • no recent global data (to our best knowledge)

16. 2. MIC health policies Comparing Colombia, Chile and Costa Rica • Colombia, in vivo test of health care privatisation in developing countries. Int J Health Services • Costa Rica: Achievements of a heterodox health policy. American Journal of Public Health • Chile, a neoliberal success story? PLoS

17. Old inter-country comparisons Notice: 16% of Chilean population consumes 50% of health expenditure

18. Health and Equity Indicators Costa Rica vs United States (2002)

19. MIC/US health policies: a universal model

20. The new international health policy objective: universal coverage • Promoted by France, Germany, USA… • And WHO (WHR 2010) • Alleged justifications: • out-of-pocket expenditure hampers access • chronic diseases become a burden (demographic transition) • Objective: open LMIC middle class market of health insurance to high income countries banks • Example: main Chilean Isapres belong to 3 EU / US banks

23. Misleadinguniversalinsurancecoverage • Colombia 1997-2003: • insurance coverage rate from 54% up to 62% but • outpatient consultation rate 23.8% down to 9.5% • Peru 2007 – 2008: • social Insurance coverage from 42,7 up to 63,5% in extremely poor population and from 26.6 to 44.7 in the other but • those who didn’t consult increased from 50.5 to 56% • Burkina Faso 2008: • Made C-sections free at the point of delivery but • c-section rate up by 20% only • Ghana 2007 -2009: • insurance coverage increasing from 0% to 60% but • user fees increased from 9 to 11% of total health expenditure

24. (Insurance!) universalcoverage, a fashionablestrategyunlikelytowork All these examples point to the existence of significant non-financial barriers to • access to individual health care • limited effectiveness of health insurance in LMIC • the lure of focusing public financing on the poor (≠ Western Europe)

25. Whydidsocial health insurancesfail in LMIC? Because • paradoxically, governments focused public financing / social insurance on the poor! • …which led middle classes to deny any contribution to health care public financing as they couldn’t take advantage of it • To the contrary, in Western Europe, social organizations forced a single universal pooled prepayment system

26. Whydidsocial health insurancesfail in LMIC? Because of limited effectiveness of regulation and control in LMICs • Hesvic project: evaluation of regulation in Chinese, Vietnamese and Indian maternal health sectors 8 / 9 = failures; 1 / 9 = central planning • Failure of PFP in Costa Rica • Failure of Chilean and Colombian health policies are partly linked to failures of their ‘superintendencia’ (contraloria) • Mechanisms are related to LIC / MIC States features

27. The international policy undermine LIC health systems Segmentation and fragmentation of systems • Management property split = commercial privatisation of public hospitals (ex. China) • Municipalization of health services (from Philippines to Brazil) • Bolivia: 4 authorities (national and local governments, region, and international cooperation) for 1 health centre

28. The hiddenmotives of this policy • 16% of GDP (USA) – 8% of GDP (Spain)= 8% of the world GDP • The biggest worldwide market to earn?

29. Past and future GDP at market prices (trillions of euro)

30. Non health economic actors will lose market shares if Europe health system moves towards a US like one

31. Alternative options in health care delivery policies

32. A new MDG: universal access to versatile, individual health care • family and community medicine • general hospital care • disease control • integrated control of social determinants

33. Instead of insurance coverage indicators, promote indicators of access to decent care Examples • Hospitaladmissionrates • First line utilisationrates • TB and AIDS case fatalityrates • Referralcompletionrate None of them are requestedby WHO / releasedbycountries!

34. Such care should meet simple quality criteria Care should be • continuous (to avoid resistance to antiretroviral and TB statics) • integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs) • bio-psychosocial (to be effective /acceptable) • effective e.g. tuberculosis case fatality rate • Efficient(to be compatible with solidarity) • Not-for profit(to be compatible with the Hippocratic Oath)

35. Promote a health sector with a social mission

36. Strategic priorities for health systems strengthening • Integrate and strengthen the sector of publicly oriented(socially motivated) health care delivery • Integrate administration of disease control programs into general health care management • Strengthen bio-psychosocial care in first line • Strengthen general hospitals • Coordinate first line services + Hospital in a local health system to improve care coordination and knowledge transfer • Steer field experiments • Promote bottom up planning towards national health policy

37. Addressing fragmentation with integrated networks H Interinstitutionalmanagement of local healthsystems Professional management and deconcentratedbudgets are needed

38. 4. Alternative options in health financing Let’s not target the poor with public financing if we want national solidarity and equity Let’s export the principles of the West-European health financing system

39. MoH Taxes (or Bismarkian) National health fund Demand-side financing Commercial sector Not for profit private org. MoH services Social sector Individuals Analternativefinancingpatternforsegmentedhealthsystems Notice: supply side financing doesn’t permit to only finance MOH services

41. Thank you jpunger@itg.be www.jeanpierreunger.com