Coverage decision-making under universal health coverage

1. Coverage decision-making under universal health coverage Dr. Jeanette Vega Washington DC, March 11 2013

2. Presentation Overview Universal Health Coverage (UHC): Definition and concepts 1 Implementing UHC: 2 Country case study 3 4 Final reflections

3. Universal Health Coverage Definition: All people can access the health services they need without incurring financial hardship. Indicators: Access Financial protection

4. UHC is Not Only Health Financing Inputs & Processes Health Financing Health Workforce Infrastructure Information Governance Service Delivery Outputs Service Access and Readiness Service Quality and Safety Service Utilization Prepaid Funds Outcomes Coverage of Interventions Coverage with a Method of Financial Risk Protection Risk Factors Impact Health Status Household Financial Wellbeing Responsiveness Level and Distribution (equity) Social Determinants

5. Presentation Overview 1 Implementing UHC 2 3 4

6. Towards Universal Health Coverage Source: Evans DB et al The World Health Report Health Systems Financing. The Path to Universal Coverage The World Health Organization 2010

7. Who should be covered?: Full population coverage for a priority package of services

8. Most of countries: segregated systems

9. How to pay for UHC?

10. Defining priority setting in health “the task of determining the priority to be assigned to a service, a service development or an individual patient at a given point in time”. (NHS, 2009)

11. Why priority setting? • Becauseclaims (whether needs or demands) on healthcare resources are always greater than the resources available. • Because the absence of or ad-hoc priority-setting approaches can disproportionately impact the least well-off and distort a national health system’s ability to progress towards UHC. • Because healthcare costs growth is always greater than income growth • To increase efficiency and equity of health funding.

12. The opportunity for policy-makers • Many applications for priority-setting • Achieving national objectives • Allocating resources • Defining the benefit package • Introducing and assessing new technologies including drugs

13. Criticalprioritysettingchoices and levels Macro Government, national agencies • critical choices for priority setting and resource allocation: • Forms of treatment that should be available • through public funding • Proportion of public revenues allocated to health • Distribution of the health budget between geographical areas/population aggregations • Proportion of available funds spent on capital development relative to operating costs • Allocation of resources to different levels of the health service and to specific disease control programs • Definition of who should be eligible to receive such treatment • Definition of the amount to be spent on individual patients Meso Health system providers Public, consumer and provider input Micro Individual providers

14. children women ethnic groups Low SE groups workers Rural groups Eg: CANCER primary care secondary care tertiary care rehabilitation long term care Vertical Population based priority setting Population groups prevention seniors Leads to Cancer care (vertical priorities) Leads to population priorities end of life care Leads to: BENEFITS PLAN Horizontal priority setting Cancer Diabetes All children Primary care

15. Faster progress by prioritising universal entitlement to a defined benefit package

16. IdentifyingCriteria for definition of benefit packages Are effective interventions available? Magnitude:Burden of disease and Perceived needs Equity Risk-harm criteria Value for money: Cost-effectiveness feasibility of supply Countries consider a wide variety of issues including equity, efficiency and severity of disease. Ranking and weighting of these considerations varies across countries.

17. Costing a BP: Chile’s case Chile's case-study Chile's “segregated health system” • Chile relies on mandatory social health Insurance (SHI) to provide universal coverage to its population. • Segregated system public/private. • Fonasa, the single public insurer, covers 80% of the population Government’s subsidy (General taxation) Public Health Goods Public Insurer, National Health fund (FONASA) Private Insures (Isapres) Insurers Mandatory 7% Mandatory 7% Optional Complementary Payment Population in Public Sector Population in Private Sector Population Reimbursement Reimbursement B C D A Contributing Affiliates Indigent AUGE BP AUGE BP Copayments Copayments Fee-for-Service Providers Public Providers Private Providers Free-Choice Modality: Copayments Financing Health care services

18. Chile: A segregated health social security system • Isapre beneficiaries belong mainly to the two upper income quintiles.

19. How to break the divide? A system-wide benefits package…did work: “AUGE” Financing of MOH operations Ministry of Finance Ministry of Health Subsidies (a) to finance non-AUGE services for the indigent population and the retired and (b) to co-finance AUGE services for all beneficiaries Policymaking and delivery of public health National Health Fund (Fonasa) Public Social Insurer 76.5% of population Isapres Private Social Insurers 17.5% of the population Insurers 7% mandatory premium 7% mandatory premium Additional voluntary premium The retired Indigent population (Group A) Lower- and lower-middle-income workers and families (Groups B, C, and D) Upper-middle and high income workers and their families Population Mostly fee-for-service payments Budgets and output-based payments AUGE AUGE Copayments Copayments Copayments Private providers Public providers (National Health Services System, SNS) Providers Fee-for-services and case-based payments Financing flows Non-AUGE + AUGE services

20. Chile’s Health Reform in 2005 (AUGE)On top of UHC system with traditional guarantees Explicit 4 additional guarantees for 80 priority health events • Access: FONASA and ISAPREs legally bound to cover explicit benefit package of guaranteed health interventions related to 80 priority health problems. • Quality: Health interventions to be delivered by properly registered and certified provider, according to standardized clinical guidelines. • Opportunity: Health interventions must be delivered within explicit maximum time periods. • Financial protection: FONASA and ISAPREs must cover at least 80% of guaranteed package of health benefits. Access Quality Isapre Opportunity Fonasa Financial Protection

21. AUGE’s prioritized list of 80 medical problems

22. Implementation issues Process of AUGE Priority Setting 22 1. Importance according to burden of disease 4. Importance of financial burden to households 3. Feasibility of supply to Provide treatments 2. High cost effectiveness of available treatment 5. Social consensus on priorities Included in the AUGE benefit plan

23. Costing methods to calculate the cost per disease included 23 1320 different health interventions Demand estimation Price estimation 446 56 10% Intervention 1 Price1 Partial mastectomy 90% Problem AUGE 1 ISj1 85% End-Stage Renal Disease Intervention 2 Price2 Surgical intervention Radical Mastectomy 7% Intervention 3 Price3 80% Problem AUGE 8 Breast echography ISj1 Breast cancer Other Pricez Chemotherapy Problem AUGE 56 Premium estimated at: US$140 per beneficiary in public sector ISj1 ECT Radiotherapy

24. Final benefit package is a mixed of

25. Conclusions • Advancing toward UHC includes defining: who should be covered?, how to pay for it, and what services should be covered first. • Priority setting is a complex, political and “muddy” process • Various tools for priority setting. Need to consider process and outcome when evaluating success • Priority setting usually translate into definition of the benefit package. • The benefit package must be constructed based in the local context, with explicit prioritization criteria and enforceable guarantees • Goal is that intentions meet the reality of advancing towards UHC • Need to monitor and measure to ensure

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