Health care financing in the ACP countries ACP-EU Joint Parliamentary Assembly, Committee on Social Affairs and the Environment March 20th 2015 Professor Bruno Meessen, Institute of Tropical Medicine, Antwerp
Health sector • Till recently, health was mainly a technical matter – for Ministries of Health, specialised aid agencies and doctors • It will be more and more also a political matter – this creates new responsibilities for MPs. 2
My focus • Why health will be more and more a political matter? • What’s going on in many countries? • What are the implications for MPs. 3
Why investing in health? • A key human right - health valued per se Global health 2035;: a world converging • Good for prosperity within a generation, D.T. Jamison et al 1013, Lancet, vol 382, December 7 • Citizens ask for it 4
Health as a political matter • Health expenditure / GDP • Drivers: new needs, new demands, new solutions, inefficiencies 5
A new era: results matter 6
Ongoing processes and implications for MPs 7
Focus on two high-level (overlapping) agendas • Value for Money • Universal Health Coverage • Both are key for the ACP populations and MPs have a key role to play. 8
1. Value for Money • High Level Ministerial Dialogue on Value for Money, Sustainability and Accountability in the Health Sector, Tunis, July 4-5, 2012. 9
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 1. Intensify dialogue and collaboration between our respective ministries and with technical and financial partners . • Health care financing has three main components: budget/collective resources, out- of-pocket, aid. Aid instruments and out-of- pocket have monopolized the attention, but the revolution will actually be at the level of the budget/collective resources. A key role for MPs. 10
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 4. Design effective investments in the health sector, based on evidence-based strategies leading to the prioritization of high impact interventions, which lead to results. The identified high impact health interventions should be mainstreamed in the comprehensive national health financing strategies with a regular budgeting and financing system; • Part 1 of the ‘budget revolution’ – a new logic you will have to get familiar with. 11
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 5. Promote equitable investment in the health sector; ensure that health financing is pro-poor benefiting disadvantaged areas... • Part 2 of the ‘budget revolution’ – Monitor distribution of benefits. Huge political relevance! 12
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 6. Lay out the path to universal health coverage for each country, in particular establishing mechanisms to ensure equitable access to essential health services including social health insurance while ensuring effective safety nets to protect vulnerable individuals, households and communities ; • See further – European Union can develop leadership on UHC 13
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 7. Improve efficiency in health systems, including equitable access to skilled health workers and the introduction of measures such as results based financing and incentives to enhance transparency and performance and reduce wastage ; • Part 3 of the ‘budget revolution’ – the way you provide the resources is as important as the amount. A reform agenda! 14
Results Based Financing Results Based Financing Number Unit price Total earned provided ($) ($) Child fully vaccinated 100 5 500 Skilled birth attendance 20 10 200 Curative care <5 years 1,000 0.5 500 Total before correction 1,200 Remoteness Bonus + 50% 1,800 Quality correction x 60% 1,080 $1,080 available for: • Health facility operation costs (supplies, maintenance, outreach etc) – about 40% of funds • Performance bonus to health workers – about 60% of funds 15
Results Based Financing (World Bank) 16
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 8. Solidify sustainable health financing systems that build on and coordinate the diversity of sources of finance including institutional health financing and better coordination and predictability of external resources to ensure that all have access to good quality essential health services; • Message mainly to the partners. Still quite some work to be done (Paris Declaration 2005). A demand by MPs (Lagos 6/2014) 17
Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 9.Strengthen accountability mechanisms that align all relevant partners, build on the growing citizens’ voice and ensure the highest possible level of results for the money spent; • A revolution in the making: open data combined with mobile technologies. It is not ‘more of the same’. 18
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Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector • 10. Increase domestic resources for health through enhanced revenue collection and allocation, re-prioritization where relevant and innovative financing, giving priority to immunizations, non-communicable diseases, AIDS, Tuberculosis and malaria, as well as reproductive, maternal and child health in national budgets. • Key role of Ministries of Finance, Budget Commission of the parliament… 20
2. Universal Health Coverage (UHC) • United Nations resolution on universal health coverage, New York, 12/12/12 21
The World Health Organization UHC cube Three dimensions: population coverage, service coverage, • financial protection. It is an umbrella goal for health, contributing to sustainable • development & human wellbeing. World Health Report 2010: Health systems financing – the path to universal health coverage. Geneva, World Health Organization http://www.who.int/whr/2010/en/
Universal Health Coverage: issues at 3 levels Politics Health Human Economics rights 23
Universal Health Coverage (state of knowledge) Politics a rights-based approach (e.g. constitution), a focus on equity and vulnerable groups Health Human Economics rights 24
Universal Health Coverage (state of knowledge) democratic political Politics systems, strong left-party organising a high tax revenue base, low levels of social fragmentation, collaboration across sectors, strong political will Health Human Economics rights 25
Universal Health Coverage (state of knowledge) Politics No single road, and no universality without equity and efficiency , ownership is key, innovation helps Health Human Economics rights 26
Fragmentation of health care financing Study in 12 Francophone African countries: 23 schemes in average (Kelley et al 2014) 27
Universal Health Coverage: issues at 3 levels Politics Political economy Health Human Economics rights 28
Political economy: dealing with three powers Economic power / vested interest Reformers Ideas Electoral and ethical majority norms 29
Recommendations for ACP MPs • Prioritise health in bilateral and multilateral cooperation and national budget • Embrace your new roles, develop command on key matters, make your voice heard (constituency, government, media, etc.) 30
Recommendations for MEPs: • Support existing commitments (e.g. Paris Declaration) • Promote UHC, a great umbrella goal, strongly aligned with European values and experience • Include ambitious language on health in the ‘Financing for Development’ EP report • Think laterally (e.g. the impact on health of other key EU policies) and forwardly (e.g. innovation). 31
Annex 32
ACP MPs: The 5 questions to your Ministry of Health / Government 1. Are your priorities evidence-based and focusing on high impact interventions? 2. Can you demonstrate that your budget allocations are reaching the poorest? 3. Can you explain how your choices address the inefficiency in the health sector? 4. How have you coordinated with other ministries and sector to advance the Universal Health Coverage agenda? 5. What have you done this year to obtain more accountability from donors? (off-budget resources) 33
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