Session I: International Experience
Thai Health System in Transition: Achieving Universal Coverage?
by Dr. Siripen Supakankunti, Thailand
The health care and delivery system in Thailand today faces severe inequities and inefficiencies. If the universal coverage program is to reach its full potential, the policy will require several more revisions and changes. Some issues will be more easily revised and fixed than others. Changing the structure of the system to encourage patients to utilize health care facilities, or to require physicians to prescribe generic drugs when available, however, is simply a matter of documentation and dissemination of information. Longer-term projects that require larger investments must first be evaluated for cost-effectiveness to insure that they are worth the significant time and financial investments. With the constant evaluation and monitoring of these issues in the health care system, Thailand will reap benefits, not only through the improved health of its citizens, but also through increased productivity and subsequent economic development of the country.
South Asian countries intending to move towards public provision of universal health insurance should understand that there is no plan that can treat every illness for every person in the system. Before policy implementation, and even prior to policy proposals, a study of the current health status of the population and the existing health care system in place should be carried out. Analysis of the health status will highlight the areas in which the population is lacking services, as well as allow policy makers to see which programs should have the largest impact on the health of the population. Analyzing the health care system allows policy makers to identify the current inefficiencies and gaps in provision. Based on these studies, policy-makers should set reasonable goals for its program of health care coverage, and set up statistical indicators to allow the government to monitor the success or failure of the program, and analyze where the program may need revision. Finally, it is crucial for policy-makers to know and understand that no policy will be perfect forever. Changes must be made to policy, according to demographic changes and according to public response to the program. Thus, it is vital that policy-makers continue to frequently monitor the progress of the program and implement changes accordingly.
Universal Coverage and Equitable Access to Health Care: Lessons Learned from the German Health Insurance System for Low and Middle-Income Countries
by Paul Rueckert and Friedeger Stierle, Germany
At present, a series of low and middle-income countries are either starting to introduce Social Health Insurance (SHI) schemes or aiming at the improvement of existing schemes in their countries. The German health insurance system has been in existence for more than 120 years and can provide lessons for the development of SHI. However, it is understood that a simple system import will never succeed without considering the historical development, economic situation and cultural values.
The German health insurance system is based on three principles: solidarity, decision-making at the lowest level possible and free choice of providers. The ethical policy is that everyone should have access to the same benefit package and the same quality of care on equal terms. Health insurance in Germany initiated from small, voluntary, community financed health insurance schemes called “sickness funds”. The introduction of compulsion, an essential element of SHI, led to expansion of the schemes and eventually universal coverage. In due course, sickness funds started merging, thus achieving higher risk pooling. Germany still has a pluralistic, decentralized system. The government only plays a steering and regulatory function. Sickness funds are self-governed, an interesting alternative to public and private market schemes. Over time, the SHI benefit package was adapted in accordance with changing needs and economic conditions. Germany also gained valuable experiences regarding cost control of its predominantly fee-for-service system that might be adapted and adopted, even before SHI is launched. The concept of SHI and continuing experiences in Germany provide interesting examples for policy-makers, which need to be studied further in their respective countries’ context.
(Un) Masking Policies of Health Care Finance
by Dr. Peter Coyte, Canada
The aim of this article is to deconstruct health policy discourses in the area of health care finance that are often taken for granted. This post-structural posture will allow for the identification of ‘exclusionary’ health policies, which we define as policies that are thought to offer universal benefit, despite yielding adverse effects for significant segments of society. One such policy concerns the increasing emphasis on private finance for health care. These policies are sometimes described as being designed “for all”, but frequently benefit only a subset of the population. Our intent is to: explore the basis for these financial policies in health care; gauge their intended and unintended effects; and finally, to examine the circumstances under which such policies are created, maintained and enforced. In order to initiate dialogue, a simple conceptual representation is outlined that highlights the factors that support the development of financial policies that result in social exclusion/inclusion. Such policies may be explicit representations of power in society or may be subtle in providing for individual “choice” and “freedom” that, in turn, yields separation (or segmentation) as an outcome. We conclude by outlining implications for South Asian countries. Specifically, we suggest that if those who benefit from financial policies of partition are numerous, if they are to obtain significant advantage (or incur limited costs) in advancing their position, or if those adversely affected are scarce/hidden (or perceived to suffer only marginally), then partition more likely becomes a “legitimate”, but exclusionary, instrument of health care financial policy.
Establishing Social Health Insurance in Indonesia: Concepts, Processes and Lessons
by Hasbullah Thabrany, Indonesia
In Indonesia, the concept of social health insurance (SHI) has been poorly understood. The general understanding is that SHI is not pro-poor, hence the hurdles that are being faced in its implication. In the late sixties, a social health insurance scheme was introduced in Indonesia and was implemented in a way that covered only government employees and their family members. This social health insurance program did not expand or increase its coverage to more people. It was in the 1990s that the Ministry of Health in Indonesia introduced and promoted the concept of commercial health insurance schemes modeled after the Health Maintenance Organization (HMO) of the United States. With the assistance provided by the German Technical Cooperation (GTZ), the concept of SHI was introduced as PROAKSI, (an Indonesian acronym for Social Health Insurance). More recently, the Indonesian Parliament amended the Constitution to mandate the Government to establish a social security system for all. The concept of Social Health Insurance then flourished quickly and has now been integrated in the Bill of National Social Security. This paper explains the concepts and processes involved in introducing and implementing social health insurance in Indonesia, highlighting conflict of interests of various parties: employers, employee associations and politicians. The paper explains how the process of implementation of Social Health Insurance in Indonesia was not easy and entails useful lessons for other countries that are going through a similar process
Session II: Regional Experience
Alternative resource mobilization strategies for Pakistan's health care
by Dr. Shafqat Shehzad, Pakistan
Improving ways to finance health care has been the guiding force for improving health outcomes in many developing and developed countries. However, total spending on health varies sharply across countries. Whereas, in many developed countries, populations enjoy universal access to range of health services financed through general tax revenues, social insurance, private insurance and user charges, in many low -income countries, financial protection against the cost of illness is still incomplete. The proportion of populations sharing risk is low, and differential between access to health care services among the rich and poor is very wide. The paper presents evidence on current practices of Pakistan's health care finance and delivery and suggests ways through which alternative resource mobilization strategies can be devised for health care in Pakistan. Some of the suggested measures are (i) improving efficiency of existing health care services (ii) reallocation of resources within the health sector and (iii) reallocation of resources from other sectors. The criteria for choosing a financing system is proposed that takes into account factors like ease of use of the system, revenue -generating ability, effects on service provision and community participation.
Public Private Partnership in Health:A Global Call to Action
by Dr. Sania Nishtar, Pakistan
The need for public-private partnerships arose against the backdrop of inadequacies on the part of the public sector to provide public good on their own, in an efficient and effective manner, owing to lack of resources and management issues. These considerations led to the evolution of a range of interface arrangements that brought together organizations with the mandate to offer public good on one hand, and those that could facilitate this goal through the provision of resources, technical expertise or outreach on the other. The former category includes governments and intergovernmental agencies and the latter, the non-profit and for profit private sector. Though such partnerships create a powerful mechanism for addressing difficult problems by leveraging on the strengths of different partners, they also package complex ethical and process-related challenges. The complex transnational nature of some of these partnership arrangements necessitates that they be guided by a set of global principles and norms. Participation of international agencies warrants that they are set within a comprehensive policy and operational framework within the organizational mandate and involvement of countries requires legislative authorization, within the framework of which, procedural and process related guidelines need to be developed. This paper outlines key ethical and procedural issues inherent to different types of public-private arrangements and issues a global call to action.
Health Care Financing in Kerala: Lessons for South Asia
by Dr. Talib Hussain Lashari, Pakistan
Historically, the exemplary achievements of the State of Kerala, India regarding the health status of its population, are characterized by factors other than health sector interventions. These factors include universal literacy, agrarian reforms, empowerment of the poor, public distribution of food and social reform movements. However, the Government of Kerala’s commitment towards high spending in the health sector has also played a significant role.
The state governments have remained committed to the growth of the health sector. This is evident from the fact that health and education have been getting a major share of the government’s development expenditure. Till the early 1980s, the annual compound growth rate of health expenditures remained 13.04%, outperforming both the annual compound growth rate of total government expenditure and annual compound growth rate of the state domestic product.
Such an enormous commitment culminated into the expansion of health infrastructure from 1961 to 1986. Due to the overall investment in health, Kerala has an infant mortality rate of 13/1000 live births compared to 69/1000 live births for India. The maternal mortality ratio of Kerala is 121/100000 live births while that of India is 410/100000 live births. The literacy rate is 92.92% compared to India’s 64.1%.
This paper reviews the literature with an objective to assess health care financing modes and patterns in Kerala; to assess the impact of health care financing on health status and; provides lessons for other South Asian countries and regions with some specific recommendations.
The paper recommends that, keeping in view the fact that achievements in health in Kerala are combined with challenges, the government’s role of stewardship should be maintained so as to keep intact an equitable and efficient health system. Collaboration with civil society should be strengthened. Most importantly, South Asia should study the Kerala health model, which carries crucial lessons for the rest of the region.
Health Care Financing: Overview and Prospects for Pakistan’s Forthcoming Five-Year Plan
by Mr. Matiullah Khan and Dr. Fazl-e-Hakim Khattak, Pakistan
This paper presents evidence for Pakistan’s health care financing practices, prospects and future plans. In Pakistan, there are wide disparities in health service provision and overall, the health sector remains under funded. Health as a social protection strategy, therefore, requires structural change in health services provision. This paper discusses Pakistan’s current health practices in (i) access and (ii) delivery and presents evidence from previous national health policies in Pakistan.
Based on the evidence that there is strong under provision of funds for the health sector, the paper proposes strategies for health care finance. Broadly they include increased services by the public and private sector, public-private partnerships and others. The paper discusses government strategies for the next five-year plan for health for scaling up resources and setting up a group of technical experts on health financing to review the (i) existing patterns (ii) efficiency of administration (iii) budgeting (iv) cost control in government health facilities (v) forecasting and (vi) resource mobilization. While the Sustainable Development Conference provides an excellent forum for opinions of academics, researchers and policy makers, the paper welcomes views and comments for consideration of the Ministry of Health.
