The Devil is in the Details: Designing and Implementing UHC Policies that Reach the Marginalized
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The document discusses the design and implementation of Universal Health Coverage (UHC) policies targeting marginalized populations, drawing lessons from the experiences of Latin America and Caribbean, as well as middle-income nations like the Philippines and Indonesia. It highlights successes in coverage expansion and reductions in out-of-pocket spending, while also acknowledging persistent inequities and challenges in coverage equality and financial sustainability. Key strategies for effective UHC implementation include strong legal frameworks, stakeholder engagement, and the careful balancing of affordability and comprehensiveness.
The Devil is in the Details: Designing and Implementing UHC Policies that Reach the Marginalized
- 1. The Devil is in the Details Designing and Implementing UHC Policies that Reach the Marginalized Suneeta Sharma, PhD Prince Mahidol Award Conference, January 29, 2017 Courtesy of Department of Foreign Affairs and Trade
- 2. Decisions to increase coverage of essential health services for all, especially reaching the marginalized and poor, need to cover a variety of domains going beyond the “cube.” UHC is not only about health financing decisions, but a converging set of health policy strategies and options. The devil is in the details. How did countries approach this, where are they now, and where are they heading? 2 Beyond the Cube
- 3. • Learning from the Latin America and Caribbean (LAC) experience • Progress in middle-income Asia • Applying the lessons in low-income settings • Summary 3 Outline
- 4. The Latin America and Caribbean Experience Courtesy of World Bank Photo Collective
- 5. 5 Where are LAC countries at and when did they start? Year of critical UHC policy Groups to cover/original focus Chile (FONASA) 1981- Those not covered by contributory insurance Costa Rica (CCSS) 1984- Entire population Brazil (FHS) 1988- Entire population Colombia (Subsidized Regime) 1993- Those not covered by contributory insurance Guatemala (PEC) 1997-2014 Rural population, especially poor Peru (SIS) 2002- Entire population Jamaica (National Health Fund) 2003- Chronic disease and the elderly only Mexico (Seguro Popular) 2003- Those not covered by contributory insurance Argentina (Plan Nacer) 2004- Mothers and children not covered by contributory insurance Uruguay (SNIS + FONASA) 2007- Entire population Health Insurance Coverage, 2015 Source: World Bank, 2015 and IDB, 2014
- 6. Co-existence of high coverage of insurance & inequities in LAC Gaps in reproductive health access by indigenous or ethnic origin Gaps in maternal, newborn, and child health access by wealth quintile have closed over time, but not everywhere Skilled birth attendance by country, year, and quintile Proportion of women who accessed skilled birth attendance, by DHS year Source: Lancet 2015 0% 20% 40% 60% 80% mCPR among women married or in union Total population Indigenous population mCPR: modern contraceptive prevalence rate Source: DHS or national surveys
- 7. What worked in LAC: • Increased share of population covered by explicit guarantees—46 million people added since 2006 • Heavily subsidized programs have started and maintained coverage • Reduced out-of-pocket spending • Equalized benefits across groups Remaining challenges • Some inequities remain—all gaps not closed for poor or indigenous • Huge diversity: Guatemala, Haiti, etc., are much behind • Covering all services equally is a challenge—partly financial, partly policy implementation Summary: Choices have consequences, which proper design can anticipate Cost per person, US$ (2011) As % of per capita GDP (2011) Chile (FONASA) $313 2.2% Costa Rica (CCSS) $589 6.8% Brazil (FHS) $125 1% Colombia (Subsidized Regime) $120 1.7% Guatemala (PEC: closed) $7 0.2% Peru (SIS) $16 0.3% Jamaica (National Health Fund) $108 2% Mexico (Seguro Popular) $122 1.3% Argentina (Plan Nacer) $42 0.4% Median $39 1.4%Source: World Bank, 2015
- 8. Progress in Middle-Income Asia: Philippines and Indonesia Courtesy of Ikhlasul Amal
- 9. 9 Philippines PhilHealth High enrollment with a limited benefits package Philippines’ path to UHC Pre-1969 1969 1996 Ministry of Health covers everyone for free Medicare - social security scheme for formal sector workers Philippines Health Insurance Corporation (PhilHealth) launched Strengths Challenges PhilHealth key characteristics as part of the National Health Insurance Program • Contributory and non-contributory (subsidized) mechanisms • Limited benefits package based on priorities: Includes key primary health care services, e.g., TB-DOTS; maternal, child, and neonatal health Low protection of the poor from catastrophic health expenditures from hospitalization Financial sustainability—unstable budget (2016 cost at estimated 75% utilization: $928 million) Membership ≠ access (difficulties enrolling poor) Hospital governance and accountability Strong legal foundation: National Health Insurance Law (1995) Strong political will Subsidized program for poor (~18% of population) 2015 81.6 million beneficiaries, 82% of the population This image cannot currently be displayed. 2010 Agenda on UHC (Kalusugang Pangkalahatan)
- 10. 10 Indonesia’s JKN scheme Growing coverage with financial sustainability challenges Indonesia’s path to UHC 2011 2014 2019 Social Security Agency formed Schemes consolidated; single payer national scheme: JKN launched Current target for universal coverage (~90%) Strengths Challenges JKN: key characteristics • Contributory and non-contributory (subsidized) elements—poor pay nothing out-of-pocket to access JKN package • Comprehensive benefits package covering all key primary, secondary, and even tertiary care needs Financial sustainability—rising healthcare costs causing increasing annual deficits Cardholding ≠ effective coverage or access— geographical and other inequities present Initially severe adverse selection—voluntary informal sector enrollment was not broad Strong political commitment and legal backing Enrollment coverage increased—172 million members in Jan 2017 (66% coverage) Explicitly subsidizes a large population of poor and near-poor (97.4 million) Series of regulatory acts and decrees Rapid scale up of enrollment (‘til 2016) 2004 National Social Security System 2012 PBI subsidy started
- 11. Applying the Lessons in Low-Income Settings Courtesy of World Bank Photo Collective
- 12. 12 Convergence in Policies • Sound legal basis: LAC, Philippines, Indonesia—all enacted legislation • Enable regulations in place; strengthen or form institutions: PhilHealth, JKN, CCSS, etc. • Purchasing based on increasing choice and efficiency • Mobilize resources to cover the poor (non-contributory) • Policies for demand generation/socialization for remote geographies and all ethnic groups • Design benefits package to cover key health needs • Engage private sector on level of contributions, provision • Engage other stakeholders Policy Implementation • Strong role of decentralized levels in monitoring and funding UHC programs • Monitor access, utilization, and quality • Ensure stakeholders have a role in periodic program evaluation and improvement Hard decisions to anticipate • Affordability vs. comprehensiveness • Sustainability of UHC-oriented scheme vs. inclusion of population groups, equity • Quality improvements with efficiency Planning for inclusion of all groups in UHC programs: no one formula 12 Thailand’s UHC Journey: The Importance of Political Will • Commitment at legislative (constitutional), political (consensus), and financial (budgetary) levels • Multi-year effort, sustained over political dispensations • MOPH leadership + network of CSOs worked together over early 2000s NHA submitted to parliament Evidence base Social movement Political will Health Reform However, there are things to look out for…
- 13. Thank you! ขอบคุณ! Courtesy of World Bank Photo Collective
- 14. Health Policy Plus (HP+) is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA- A-15-00051, beginning August 28, 2015. The project's HIV-related activities are supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). HP+ is implemented by Palladium, in collaboration with Avenir Health, Futures Group Global Outreach, Plan International USA, Population Reference Bureau, RTI International, the White Ribbon Alliance for Safe Motherhood (WRA), and ThinkWell. The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. http://healthpolicyplus.com HealthPolicyPlusProject policyinfo@thepalladiumgroup.com @HlthPolicyPlus