Challenges of the universal health coverage a review of 3 wh rs

‫السقازيق‬ ‫بطب‬ ‫المجتمع‬ ‫طب‬ ‫لقسم‬ ‫السنوي‬ ‫المؤتمر‬
29-30‫مارس‬2018
‫اإلسماعٌلٌة‬
‫فندق‬‫الفرسان‬ ‫تولٌب‬-‫العربٌة‬ ‫مصر‬ ‫جمهورٌة‬
‫بعنوان‬
Challenging the Universal Health Insurance
Coverage: Public Health Perspectives
31-Mar-18 www.SlideShare.net/AhmedRefat 1

Challenges of the
Universal Health Coverage:
A Review of Three World
Health Reports
‫من‬ ‫مقدم‬ ‫بحث‬
Dr. Ahmed-Refat AG Refat
Prof. FOM-ZU

Challenges of the Universal Health Coverage: An
Overview of Three World Reports
Prof. Ahmed-Refat AG Refat
Prof. Occupational and Environmental Medicine. FOM-ZU
SUMMARY
Background: Universal health coverage (UHC) is fast becoming a first order priority
of the global health agenda .The concept of UHC is not new. The WHO constitution
in 1948 and the Alma-Ata Declaration in 1978 both indirectly stressed UHC as an
important tool to achieve “Health for All.”. A resolution at the 58th World Assembly
in 2005 encouraged the countries of the world to embed UHC in their health systems,
and the World Health Report (2010) proposed improved financing for health care to
achieve this goal. Out of the 17 SDGs, that adopted in 2015, the eighth target of
goal 3 (target 3.8) insists : Achieve universal health coverage, including financial
risk protection, access to quality essential health-care services and access to safe,
effective, quality and affordable essential medicines and vaccines for all.
This review will presents a group of relevant UHC issues that discussed
comprehensively in the following three World Health Reports:
1. HEALTH SYSTEMS FINANCING, The path to universal coverage (WHR
2010)
2. Research for Universal Health Coverage ( WHR 2013)
3. Tracking universal health coverage: (2017 Global Monitoring Report)
The objective of this work is to identify the areas that need extra efforts from
Public Health Departments in teaching, research and training of the future doctors for
proper implementing of UHC as a promising health policy in Egypt.

(( WHR ))
www.who.int/whr
31-Mar-18 www.SlideShare.net/AhmedRefat 6Dr. Ahmed-Refat AG Refat

WHR
• 2013 Research for universal health coverage
• 2010 - Health systems financing: the path to universal coverage
• 2008 - Primary Health Care – Now More Than Ever
• 2007 - A safer future: global public health security in the 21st century
• 2006 - working together for health
• 2005 - make every mother and child count
• 2004 - changing history
• 2003 - shaping the future
• 2002 - reducing risks to health, promoting healthy life
• 2001 - mental health: new understanding, new hope
• 2000 - health systems: improving performance
• 1999 - making a difference
• 1998 - life in the 21st century
• 1997 - conquering suffering, enriching humanity
• 1996 - fighting diseases, fostering development
• 1995 - bridging the gaps

HEALTH SYSTEMS FINANCING
The path to universal coverage
2010

Research for Universal Health Coverage
2013

Tracking Universal Health Coverage:
2017 Global Monitoring Report
2017

History

13 Targets
The 8th UHC
3.8.1 S.C
3.8.2 F.R
SDG#3

UHC at the core of SDGs
• The UHC target 3.8 lies at
the core of the other 12
health targets,
• and the health goal SDG#3
itself is closely interlinked
with the other 16 SDGs,

UHC
Ensuring that everyone can
obtain essential health
services at high quality
without suffering financial
hardship.
.‫ٌتعرض‬ ‫أن‬ ‫دون‬ ‫إلٌها‬ ‫ٌحتاج‬ ً‫الت‬ ‫الجٌدة‬ ‫الصحٌة‬ ‫الخدمات‬ ‫على‬ ‫فرد‬ ‫كل‬ ‫ٌحصل‬ ‫أن‬
‫الخدمات‬ ‫هذه‬ ‫تكالٌف‬ ‫تحمل‬ ‫جراء‬ ‫من‬ ‫مالٌة‬ ‫ضائقة‬ ً‫ف‬ ‫الوقوع‬ ‫لمخاطر‬

Two Dimensions of UHC
• Target 3.8.1
• Captures the coverage dimension of UHC
(that everyone should receive the health
services they need);
• Target 3.8.2
• Captures the financial protection
dimension of UHC (use of health services
should not lead to financial hardship)

Custodian Agencies for UHC
WHO is
the designated custodian agency
for both SDG 3.8 indicators,
With the UNICEF, UNFPA* &
UN DESA** for 3.8.1
and the World Bank for 3.8.2.
* UN Population Fund ** UN Depart.of Economic and Social Affairs

The
First
Report

HEALTH SYSTEMS FINANCING
The path to universal coverage
1st

UHC Cube

WHR 2010 ‫الصحية‬ ‫النظم‬ ‫تمويل‬

Spending on Health
Measures of Financial
Protection
Catastrophic Spending
on Health
• SDG 3.8.2.

Out-of-Pocket & Direct Payments

More health
for the
money

More health for the money
Using resources
wisely
Efficiency

More health for the money
Health-care systems
haemorrhage
money
Using resources wisely

Inefficiency
•It was estimate that
20–40% of all health
spending is wasted
through inefficiency.

Hemorrhage of Money
Health-care systems haemorrhage money.
More than half of the US$
2 trillion-plus that the
United States of America
spends on health each
year is wasted;

Hemorrhage of Money
Health-care systems haemorrhage money.
the annual global health
expenditure of about US$
5.3 trillion, about 6%,
($ 300 billion) , is lost to
mistakes or corruption
alone .31-Mar-18 www.SlideShare.net/AhmedRefat 32

Eliminate un
necessary spending on medicines
•Medicines account
for 20–30% of
global health spending

Ten
leading Sources of
Health System
Inefficiency

Ten leading sources of inefficiency
Medicines:
1. underuse of generics and
higher than necessary prices for
medicines
2. use of substandard medicines
3. inappropriate and ineffective
use

1. Medicines: underuse of generics and higher than necessary prices for medicines
2. Medicines: use of substandard and counterfeit medicines
3. Medicines: inappropriate and ineffective use
4. Health-care products and services:
overuse/misuse of equipment,
investigations and procedures
5. Health workers: inappropriate or costly
staff mix, unmotivated workers
6. Health-care services: inappropriate
hospital admissions and length of stay
7. Health-care services: inappropriate
hospital size (low use of infrastructure)31-Mar-18 www.SlideShare.net/AhmedRefat 36

1. Medicines: underuse of generics and higher than necessary prices for medicines
2. Medicines: use of substandard and counterfeit medicines
3. Medicines: inappropriate and ineffective use
4. Health-care products and services: overuse or supply of equipment, investigations and procedures
5. Health workers: inappropriate or costly staff mix, unmotivated workers
6. Health-care services: inappropriate hospital admissions and length of stay
7. Health-care services: inappropriate hospital size (low use of infrastructure)
8. Health-care services: medical errors
and suboptimal quality of care
9. Health system leakages: waste,
corruption and fraud
10. Health interventions: inefficient
mix/ inappropriate level of
strategies

Switching to Generics
costs to patients could be
reduced by an average of
60% by switching from
originator brands to the
lowest priced generic
equivalents31-Mar-18 www.SlideShare.net/AhmedRefat 38

Motivate people
Health workers are at the
core of a health system and
typically account for about
half of all health spending
in a country

Improve hospital
efficiency –
size and length
of stay

Medical Error Costs
• Get care right the first time
Medical error costs money &
suffering.
• One in 10 patients in
developed countries is harmed
while receiving hospital care.

WHO
CHOICE

Assess which services are needed
WHO-CHOICE
(CHOosing Interventions that are
Cost Effective)
:provided guidance on the
cost– effectiveness of a wide
range of interventions in different
settings

The
Second
Report

Tracking Universal Health Coverage:
2017 Global Monitoring Report
2nd

SDG # 3 Target 8
Achieve universal health
coverage,
including financial risk
protection, access to quality
essential health-care services
and access to safe, effective,
quality and affordable essential
medicines and vaccines for all.

Service Coverage
• The proportion of people
in need of a service that
receive it,
regardless of quality

Service Coverage
access to quality essential
health-care services and
access to safe, effective, quality
and affordable essential
medicines and vaccines for all

Effective Service Coverage
•The proportion of people in
need of services who
receive services
of sufficient quality to
obtain potential health
gains

Tracer
Indicators
& UHC Index

Tracer indicators
Subset of
indicators that
represent overall
coverage

16 Tracer indicators
of essential health services
1. Reproductive, maternal,
newborn and child health
2. Infectious diseases
3. Noncommunicable diseases
4. Service capacity and access
4 X 4 = 16 Indicators

Tracer indicators :
Reproductive, maternal, newborn and child
health
• 1. Family planning
• 2. Pregnancy and delivery
care
• 3. Child immunization
• 4. Child treatment

Tracer Indicators:
Infectious diseases
• 1. Tuberculosis treatment
• 2. HIV treatment
• 3. Malaria prevention
• 4. Water and sanitation

Tracer Indicators:
Noncommunicable diseases
1. Prevention of cardiovascular
disease
2. Management of diabetes
3. Cancer detection and
treatment
4. Tobacco control

Tracer Indicators:
Service capacity and access
• 1. Hospital access.
• 2. Health worker density
• 3. Access to essential
medicines
• 4. Health security (IHR)

Service Coverage Index
• The UHC service coverage
index is a single indicator
that is computed based on
tracer indicators
to monitor coverage of
essential health services.

UHC Service Coverage Index

At least half of the
world’s population does
not have full coverage
with essential health
services…

• The UHC service coverage
index has a value of 64
(out of 100) globally
( Range 22 - 86 )

Moving from the minimum index
(22) to the maximum index (86)
across countries is associated with
21 additional years of life
expectancy
after controlling for gross national income per capita and mean
years of adult education.

•High UHC-index values are
associated with high life
expectancy, even after
controlling for national
income and education.

The UHC index is correlated
with under-5 mortality
rates (-0.86),
life expectancy (0.88), and
the Human Development
Index (0.91).

Specific Services

Specific Services
• More than 1 billion people live with
uncontrolled hypertension;
• More than 200 million women have
inadequate coverage for family
planning;
• and almost 20 million infants fail to
start or complete the primary series of
DTP-containing vaccine,31-Mar-18 www.SlideShare.net/AhmedRefat 65

SDG # 3 Target 8
Achieve universal health coverage,
Financial
Risk
Protection.

Spending on Health
Out-of- pocket
health
expenditures

Spending on Health
Out-of- pocket health
expenditures
( catastrophic ) when they
exceed a given percentage
(10% or 25%) of income or
consumption .
This is the approach adopted in SDG 3.8.2.

Financial Catastrophe
• an estimated 150 million people
globally suffer financial catastrophe
each year
• and 100 million are pushed into
poverty because of direct payments for
health services.
• This indicates a widespread lack of
financial risk protection

UHC Indicators
( Egypt & Some Countries )
31-Mar-18 www.SlideShare.net/AhmedRefatDr. Ahmed-Refat AG Refat
68 26.2% 3.9%

UHC Index,2015

Incidence of catastrophic health
spending: SDG 3.8.2, latest year

The
Third
Report

Research for Universal Health Coverage
3rd

EUROPEAN COMMISSION
2015

• Case-study 1
• Insecticide-treated mosquito nets
to reduce childhood mortality …ma
• Case-study 3
• Zinc supplements to reduce
pneumonia and diarrhoea in
young children……rct

• Case-study 4
Telemedicine to improve the
quality of paediatric care…operational
rs somalia
• Case-study 5
New diagnostics for tuberculosis.. Valid
ass 4 cout

The value of
Health Research
Exceptional returns

‫االستثمار‬‫الصحية‬ ‫البحوث‬ ‫في‬–(‫العائد‬‫المجسي‬)
Investing US$ 335 million.
yielded about US$ 15.2 billion
benefits to society after 10
years ) By valuing QALY &GDP)
indicating a yearly return on
investment of 46%.
‫سنوي‬ ‫عائد‬46%31-Mar-18 www.SlideShare.net/AhmedRefat 79

•The yearly rate of
return in terms of GDP
was 30% for all medical
research in the
UK

• 300% of initial
investment in cost
savings for health
Impact of biomedical
research
•in USA
Impact of investment in research

More than 450 times
the initial investment over
10 years
• Clinical trials carried out
by the National Institute of
Health in the USA

• 37-39% Estimate of the impact
of biomedical research in the
biomedical sector in mental
health and cardiovascula
diseases in UK on reducton of
mortality/morbility and on GDP

In Australia, finding that
every 1 dollar invested in
Australian health research
and development yielded, on
average, $ 2.17 in health
benefits.

•At least half of the
world’s population
still do not have full
coverage of essential
health services.
• .

•About 100 million
people are still being
pushed into “extreme
poverty” (living on $ 1.90 or less a day)
because they have to
pay for health care.

•Over 800 million people
(almost 12 % of the
world’s population) spent
at least 10 % of their
household budgets to
pay for health care.

Egypt
•‫عام‬ ً‫ف‬١٨٢٨‫م‬.‫افتتحت‬‫مصرٌة‬ ‫طبٌة‬ ‫مدرسة‬ ‫أول‬
•ً‫ف‬‫عهد‬ً‫عل‬ ‫دمحم‬‫انشئ‬“‫المجلس‬‫العام‬‫للصحة‬«
‫و‬‫هو‬‫مؤسسة‬ ‫أول‬‫صحٌة‬،‫الحدٌثة‬ ‫مصر‬ ً‫ف‬ ‫حكومٌة‬
‫الصحة‬ ‫لوزارة‬ ‫نواة‬ ‫اعتباره‬ ‫وٌمكن‬.
•‫عام‬ ً‫وف‬١٩٣٦‫م‬.‫إنشاء‬ ‫تم‬"‫وزارة‬‫الصحة‬»
•‫عام‬ ً‫وف‬١٩٢٥‫م‬.‫تم‬‫حكومٌة‬ ‫جامعة‬ ‫أول‬ ‫إنشاء‬‫ومن‬
‫بٌن‬‫كلٌة‬ ‫هناك‬ ‫كانت‬ ‫البداٌة‬ ً‫ف‬ ‫تأسٌسها‬ ‫تم‬ ‫كلٌات‬ ‫أربع‬
‫للطب‬.

Egypt
•‫بعد‬ ‫ما‬ ‫حقبة‬‫ثورة‬٢٣‫ٌولٌو‬١٩٥٢‫م‬.
•‫تم‬‫تطوير‬،‫الصحية‬ ‫الرعاية‬ ‫نظام‬‫في‬‫رئيسيين؛‬ ‫اتجاهين‬
•‫األول‬‫هو‬‫التوسع‬ً‫الرأس‬‫المستشفيات‬ ‫وبناء‬ ‫التحديث‬ ‫خالل‬ ‫من‬
،‫الخدمة‬ ‫تقديم‬ ‫لمنافذ‬ ‫التقني‬ ‫والتطوير‬
•ً‫الثان‬ ‫واالتجاه‬ً‫األفق‬ ‫التوسع‬ ‫هو‬‫خارج‬ ‫الخدمات‬ ‫مد‬ ‫خالل‬ ‫من‬
،‫الريف‬ ‫إلى‬ ‫ووصولها‬ ‫الحضرية‬ ‫والمناطق‬ ‫المدن‬ ‫نطاق‬
•‫وكان‬‫تأسيس‬ ‫خطة‬ ‫الفترة‬ ‫تلك‬ ‫في‬ ‫الصحية‬ ‫المنجزات‬ ‫أهم‬ ‫بين‬ ‫من‬
‫متكامل‬ ‫نموذج‬‫للتنمٌة‬‫المجتمعٌة‬‫من‬ ‫الصحٌة‬ ‫الوحدات‬ ‫تعمل‬ ‫الرٌفٌة‬
‫خالله‬.‫الخطة‬ ‫هذه‬ ‫تنفيذ‬ ‫في‬ ‫البدء‬ ‫تم‬ ‫وقد‬‫في‬‫الخمسٌنٌات‬‫اسم‬ ‫تحت‬
"‫المجمعة‬ ‫الوحدات‬"‫قبل‬‫عدٌدة‬ ‫سنوات‬‫من‬‫إعالن‬"‫ألما‬‫آتا‬"
(Health For All + Health in all + D (.

Number of Doctors per 1 000 people
WHO Threshold (22.8)

Cited References
1. http://www.who.int/universal_health_covera
ge/en/
2. http://www.who.int/whr/2010/en/
3. http://www.who.int/whr/2013/report/en/
4. http://documents.worldbank.org/curated/en
/640121513095868125/pdf/122029-WP-
REVISED-PUBLIC.pdf
5. http://www.ghwatch.org/sites/www.ghwatc
h.org/files/Health%20Report.pdf

Challenges of the universal health coverage a review of 3 wh rs

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