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Disclaimer: The views expressed in this paper/presentation are the views of the author and do not

necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors,
or the governments they represent. ADB does not guarantee the accuracy of the data included in this
paper and accepts no responsibility for any consequence of their use. Terminology used may not
necessarily be consistent with ADB official terms.

Governing Universal Health Coverage


and Social Health Insurance
Lessons from Global Experience
Toomas Palu
Manager, Global Practice for Health, Nutrition and
Population, World Bank Group

National Health Insurance for Universal Health


Coverage Meeting
Manila, September 27-30, 2016

Overview
1.
2.

3.

4.

Social Health Insurance in support of UHC


Global governance of UHC:
Sustainable Development Goal 3.8
Global UHC monitoring frameworks
Global health financing landscape, UHC, and SHI:
Health financing for UHC
Social health insurance, among other sources
Health financing transition
Governing social health insurance:
Governing SHI in the context of mixed systems of financing
A framework for improving SHI governance
Key challenges in effective SHI governance
Strategic purchasing as an opportunity for improving governance

Social Health Insurance in support of UHC


UHC is about ensuring that all people can use the promotive,
preventive, curative, rehabilitative, and palliative health services they need,
of sufficient quality to be effective, while also ensuring that the use of
these services does not expose the user to financial hardship.

UHC Social Health Insurance


UHC is a health system objective, not a health financing model,
and social health insurance is not a necessary precondition for
attaining UHC.
Some countries are attaining UHC without social health insurance
(Solomon Islands, Vanuatu, Kiribati, PNG, Timor-Leste, Sri Lanka,
Malaysia, Fiji).
Many other countries are attaining UHC using hybrid models:
social health insurance, demand-side financing augmented by
supply-side government tax-financing, and private OOP
financing.

Global governance of UHC


Sustainable Development Goal 3.8
Global UHC monitoring frameworks

Sustainable Development Goal 3.8

Inputs for TP presentation

WHO-WB Joint UHC Measurement Framework

Service coverage and financial


protection, with an explicit focus on
equity and on effective coverage

WHO-WB Joint UHC Measurement Framework


Preventive/Promotive:
Access to modern
contraceptives
Antenatal care coverage

Skilled birth attendance

Treatment:
ARV coverage
TB treatment coverage
Hypertension treatment
Diabetes treatment
coverage

Full immunization
Financial Protection:
OOP spending as a share
Access to improved water
of household consumption
sources
Household impoverishment
Access to improved sanitation due to OOP expenditure
Non-Smoking rates

Global UHC Dataset Indicators (Work in Progress)

Service coverage

Financial protection
% impoverished due to OOP
% catastrophic spending due to
OOP
SDG 3.8.2: Incidence of
catastrophic spending at 25%
vs insurance coverage

Multiple global initiatives supporting progress towards UHC

Innovative support network for UHC / SHP


Platform for information exchange and
dialogue; mechanism for coordination across
partners; marketplace for collaboration and
complementary investments
4 multilateral organizations, 5 bilaterals, 20
partner countries

Network of practitioners and policymakers


who co-develop global knowledge products on
health systems and UHC
Collaborative learning approach
27 countries + international, regional, and
local partners

Global health financing


landscape, UHC, and SHI
Health financing for UHC
Social health insurance, among
other sources
Health financing transition

How can countries finance UHC?

Six Different Health Financing Models

General tax
revenue
financed
(Beveridge)

Social Health
Insurance
(Bismarck)

OOP
financed

Externalfinancing

Voluntary
private
insurance

Communitybased health
insurance

12

How are countries financing UHC?

Social health insurance, among other sources

As countries get richer, a larger proportion


of health financing is from public sources,
and are prepaid and pooled

Regional variations in composition of health


expenditure in part reflect regional average
income levels. But overall, the picture is
mixed

Health systems are often have multiple financing sources,


financing agents, provider types, each with different
arrangements for financing flows

Source: Somanathan, Aparnaa,


Ajay Tandon, Huong Lan Dao,
Kari L. Hurt, and Hernan L.
Fuenzalida-Puelma. 2014. Moving
toward Universal Coverage of
Social Health Insurance in Vietnam:
Assessment and Options. Directions
in Development. Washington, DC:
World Bank.

Health Financing Transition

Share of total health expenditure (%)

70

10000

Health financing transition

60
50

2500

Rising total health spending (left axis)

500

40
30
20
10

LOWER
MIDDLE
INCOME

LOW INCOME

250

External share (right axis)

1000

UPPER
MIDDLE
INCOME

2500
10000
GNI per capita, US$

Source: World Development Indicators database

HIGH INCOME

35000

25

100

500

OOP spending share (right axis)

100000

Sustainability of externally-financed
health programs

Financial
Sustainability

Programmatic
Sustainability

Transition away from external financing as


income rises
Replacing this with domestic financing that
is pre-paid and pooled Critical to
ensuring financial protection, efficiency,
equity
Program implementation arrangements
often outside of government systems
Parallel systems, most critically
procurement, financial management, human
resources, monitoring and evaluation
Strengthening government capacity and
capabilities to take on these functions is
critical to effective transition

80 90

100

Benchmarking health financing for UHC

Thailand

Fiji

70

Sri Lanka
Indonesia

Korea

Russia

30

40

50

60

India

Costa Rica
Cuba
Brazil
Chile
Malaysia
South Africa
China

15

25

50
100
250
500 1000
2500
Total health expenditure per capita, US$

5000 10000

Source: UHC attainment index is the average of service coverage and financial protection

80

Benchmarking health financing for UHC

60

India

Indonesia
Russia

40

Sri Lanka

Korea

Malaysia
China

Chile

Fiji

20

Brazil

South Africa

Costa Rica

Thailand

Cuba

3
6
9
Government health spending share of GDP (%)

Source: World Development Indicators database

12

Governing Social Health


Insurance
Governing SHI in the context of mixed
systems of financing
A framework for SHI governance
Key challenges in effective SHI
governance
Strategic purchasing as an
opportunity for improving governance

Governing SHI in the context of mixed systems of financing


Public
accountability:
Beneficiaries,
political
commitments to
UHC

Formal oversight
institutions:
e.g. State audit
institutions,
regulators, SHI
agency boards

Funding sources:
Government,
employers, other
non-beneficiary
contributors

Other stakeholders:
e.g. health
professionals
associations, patient
groups, private
healthcare providers

Accountable to:

Social Health Insurance


Accountable for:
To support attainment of UHC:
Effective delivery of health services
Ensuring sufficient quality of services
Ensure financial protection against
healthcare costs

Within the SHI institutional arrangement:


Solvency and financial sustainability
Cost-effectiveness
Preserving clinical standards of care
Service standards (non-clinical) e.g.
client satisfaction

Source: Adapted from Governing mandatory health insurance : learning from experience , edited by
William D. Savedoff and Pablo Gottret, World Bank, 2008

A framework for SHI governance


Coherent decisionmaking structures
Stakeholder
participation
Transparency and
information

Supervision and
regulation
Consistency and
stability

Responsibility for objectives correspond with decision-making


power and capacity
All entities have routine risk assessment and management
strategies in place
Cost of regulating and administering SHI institutions is reasonable
and appropriate
Stakeholders have effective representation in the governing
bodies of SHI entities
SHI objectives are formally and clearly defined
SHI relies upon an explicit and appropriately designed institutional
and legal framework
Clear information, disclosure, and transparency rules are in place
Minimum requirements in place to protect the insured
Rules on compliance, enforcement, sanctions for SHI supervision are
clearly defined
Financial management rules for SHI entities are clearly defined
and enforced
SHI system has structures for ongoing supervision and monitoring
SHI objectives are stable
Fundamental characteristics are defined in law; law is
independent of political changes or other crises
Source: Adapted from Governing mandatory health insurance : learning from experience , edited by
William D. Savedoff and Pablo Gottret, World Bank, 2008

Key challenges in SHI governance


Coherent decisionmaking structures

Stakeholder
participation

Transparency and
information

Many SHI entities are third-party administrators with limited


autonomy to make decisions on key SHI parameters e.g.
contribution rates, composition of benefits package.
SHI entities act more as payers, not strategic purchasers.

Limited involvement from broad range of stakeholders e.g. unions,


medical professionals, beneficiaries. E.g. very few UHC programs
have a patient advocate or ombudsman function
Affects credibility of key decisions made
Absence of legal framework for disclosure of information by
program on demand by external entities
Weak information environment and/or minimal use of data or
monitoring and evaluation

Supervision and
regulation

Enforcement and compliance monitoring both of SHI and


providers often falls short (e.g. Vietnam re: balance billing,
Philippines re: monitoring provider compliance with regulations)

Consistency and
stability

Frequent changes to UHC / SHI policy, often related to political


changes
Source: Adapted from Governing mandatory health insurance : learning from experience , edited by
William D. Savedoff and Pablo Gottret, World Bank, 2008

Strategic purchasing as an opportunity for improving


governance and health system performance
Empowering
the citizen

Strengthening
government
stewardship

5 central themes
for improving
purchasing

Developing
appropriate
purchasing
organizations

Ensuring costeffective
contracting

Improving
provider
performance

Source: Purchasing to improve health systems performance, edited by Josep Figueras, Ray Robinson, and
Elke Jakubowski, European Observatory on Health Systems and Policies Series, 2005

Strategic purchasing as an opportunity for improving


governance and health system performance
Ensuring cost-effective
contracting

Improving provider
performance

Linking contracting with


planning
Establishing evidence-based
contracts
Cost and volume contracts
Paying for performance
Quality metrics in contracts

Increasing provider autonomy


Performance targets /
sanctions (managerial
accountability)
Performance benchmarking
(public accountability)

Source: Purchasing to improve health systems performance, edited by Josep Figueras, Ray Robinson, and
Elke Jakubowski, European Observatory on Health Systems and Policies Series, 2005

Funding and Accountability at PhilHealth


Philippines Sin Tax Law reformed tobacco and alcohol taxation.
Simplified and increased excise taxes, especially on cigarettes.
Sin tax revenues doubled as a share of GDP; health sector budget tripled from ~P42 billion in 2012
to P123 billion in 2016. Revenues from reform were used to finance expansion of fully-subsidized
social health insurance, especially for the bottom 40% of the population.
Significant resources came with a robust monitoring framework, including both tax and earmarking
indicators:
Overview of Philippines Sin Tax Law Monitoring Indicators:

UHC programs: Changing the way we think


about accountability in the health sector
UHC schemes are not just more of
the same (more people, benefits,
money or supply)
Strengthening accountability
including fundamental changes to
how stakeholders interact is a
common feature in many UHC
schemes

UHC programs: Changing the way we think


about accountability in the health sector
1. Moving towards arms length relationships and explicit responsibilities. E.g. Much more
purchaser-provider split, provider autonomy, use of explicit benefits packages in UHC
programs, agreements on responsibility for health across levels of government
2. Increased use of paying for outputs and results, including in provider payment
mechanisms, incentives to encourage UHC program enrolment, and in allocation of resources
from central to sub-national authorities
3. Attempts at using information for accountability. Significant data collection efforts from
UHC programs; limited effective use of data to date.
4. Efforts at boosting citizen voice and client empowerment. E.g. through legislation on
right to health, access to information laws, information campaigns, redress mechanisms.
Mixed effectiveness to date.

A good start in improving accountability in UHC programs including through demand-side


interventions but more work needs to be done

Source: Adapted from Cotlear, Daniel, Somil Nagpal, Owen Smith, Ajay Tandon, and Rafael Cortez. 2015.
Going Universal: How 24 Developing Countries are Implementing Universal Health Coverage Reforms from the
Bottom Up. Washington, DC: World Bank

Thank you!