Transcript Decent Work and the Issue of Extension of Social
Asian experiences of the extension of social security coverage - focus on health care
15 October 2007 Bangkok Hiroshi Yamabana Social Security Specialist ILO SRO-Bangkok E-mail: [email protected]
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Structure of the presentation
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‘Universal coverage’ in Asia Health case as priority Health care financing Where are we on the development?
Concluding remarks
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‘Universal Coverage’ in Asia
Major two groups Taxation group: Australia, New Zealand => High compliance Modest benefit level (in case of pensions) Social Insurance Group: Korea, Japan => Relatively low compliance Modest benefit level (in case of pensions) Relatively high copayment (health)
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Health as priority
80% of the world population does not have access to adequate social protection, most of them live in social insecurity.
Every year 100 million people globally are forced into poverty by health care costs.
Worldwide, 178 million people are exposed to catastrophic health costs.
=> Notorious vicious circle of poverty and health
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Social protection needs of non-covered population - case of Thailand
35% 30% 25% 20% 15% 10% 5% 0% Sickness Pensions Job loss Agricultural protection Child allowance Education grant Occupational injury •Pensions include “Death of income earner”, “Old-age”, “Disability”, and “Funeral” •Agricultural protection includes “Loss of harvest” and “Loss of livestock.” 7
How about affordability - case of Thailand
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Health care financing
Where is the financing coming from?
Public / private / donor financing 2.
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Who pays to medical providers?
Medical case purchase institutions (e.g. health insurance organizations)?
How is the payment paid to medical providers?
Prepayment (risk pooling) / post payment ( out-of-pocket, non risk pooling) Fee-for-service / case payment / capitation etc.
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Achieving the Health Millennium Development Goals in Asia and the Pacific, UNESCAP 2007
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Total health expenditure as a percentage of GDP 2 0 8 6 4 High-income countries Middle-income countries Low -income countries
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Public / private health expenditure per capita (OECD countries)
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Financing of global expenditure on health
40 30 20 10 0 Government expenditure: 33 % Social insurance: 25 % Private insurance: 20 % Out-of-pocket payments: 18 % Other: 4 % 13
Composition of health spending - 2001
Data estimated unsing average annual exchange rate - Timor Leste not included Taxes 100% Out-of-pocket spending Social health insurance Other private expenditure Private health insurance 80% 60% 40% 20% 0%
AFR AMR - USA EMR EUR SEAR WPR OCDE - USA USA
AFR: Africa, AMR: Americas, EMR: East Mediterranean, EUR: Europe, SEAR: South East Asia, WPR: Western Pacific Source: NHA Unit, EIP/FER/RER, World Health Organization 14
Public expenditure on health as a percentage of total health expenditure Low -income countries Middle-income countries High-income countries 0 20 40 60 80
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Prepayment in the OECD countries 14 12 10 8 6 4 2 0 3 40% 50% 13 7 4 2 50% 60% 60% 70% 70% 80%
Prepayment ratio*
80% 90% 1 90%+ *
Health expenditure financed via UC health financing system/total health expenditure,
Source: WHO
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Prepayment ratios in selected SHI systems (2001)
Country
Austria
Prepayment Ratio (%)
69.3
Country
Israel
Prepayment Ratio (%)
69.2 Belgium 71.7 Japan 77.9 Costa Rica France Germany 68.5 76.0 74.9 Luxembourg Netherlands ROK Switzerland 89.9 63.3 44.4 57.1 Source: WHO (2001) 18
90% 80%
Health Care Financing Profile of WPRO and SEARO Regions-2001
Myanmar India Cambodia 70% 60% Indonesia Singapore Viet Nam Nepal China Bangladesh 50% 40% Philippines Sri Lanka Malaysia Lao Vanuatu Thailand Fiji Tuvalu Cook Isl.
Tonga S.Korea
Marshall Islands 30% 20% 10% DPR Korea Brunei Bhutan PNG Solomon Isl.
Mongolia Samoa Maldives Nauru Japan N.Zealand
Australia FSM East Timor Niue Kiribati Palau 0% 2.00% 4.00% 6.00% 8.00% 10.00%
Total Health Exp. as % of GDP
12.00% Source: WHO (2001) 19
Increasing share of private financing
Total HE, % Government, % Private HE,% Samoa Fiji 100.0
100.0
Cook Islands 100.0
Malaysia 100.0
Tonga Philippines Lao PDR China Viet Nam Cambodia 100.0
100.0
100.0
100.0
100.0
100.0
Source: NHA report. WHR-2004 76.2 65.2 62.8 58.8 46.8 45.7 38.0 36.6 25.8 24.5
23.8 34.8 37.2 41.2
53.2 54.3 Minimal financial protection, limited risk sharing and fund pooling practices
World Health Organisation
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Where are we on the development?
Source: Achieving the Health Millennium Development Goals in Asia and the Pacific, UNESCAP 2007
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Country China India Indonesia Kenya Lao People's Democratic Republic Mongolia Philippines Senegal
r F o m
Insurance schemes
l – – – – – – – – – – – – – – – – – – s Urban workers i c Basic insurance a RCMS (new) l EISIS h e CGHS a l CBHI t h ASKES p JAMSOSTEK r o CBHI t e NHIF t c CCS i o n SSO CBHI r c o v National scheme Phil Health CBHI IMPs MOH a g e f o i n % u l a o p p
Estimated formal coverage ( in % of total population) 10 20 20 7 5 78 55 11.4
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Source: Social Health Insurance, Selected Case Studies from Asia and the Pacific, WHO 2005 23
Source: Social Health Insurance, Selected Case Studies from Asia and the Pacific, WHO 2005 24
Development of Thailand
Source: Dr. Pongpisut Jongudomsuk, NHSO, Thailand 25
Japanese experiences on extension of coverage
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Source: Prof. William C. Hsiao, Harvard University 30
Example of different approaches
1. Developed countries Australia, New Zealand Tax-based universal scheme Japan, Korea Social insurance approach (substantially subsidized, e.g. 50% benefit cost of self employed in Japan, 40% in Korea) with a supplement of social assistance Singapore Social insurance approach, mixes of individual savings and risk-pooling for high-cost care 31
Example of approaches of different countries
2.Middle-income countries Thailand Mixed approach of social insurance (private-sector workers) and tax-based approaches for civil servants and the others Malaysia, Sri Lanka Tax-based public medical institutions (low charges or free-of-charge) plus private insurances for some companies 32
Example of approaches of different countries
3. Developing countries Vietnam Mixed approaches of totally subsidized persons (e.g. war veterans, the poorest), compulsory insured persons (formal-sector employees) and voluntary insurance (CBHIs)
under one umbrella (VSS)
Lao PDR Mixed approach of compulsory social insurance (private and public-sector workers), voluntary insurance (CBHIs) and totally subsidized persons by donors (HEFs) Cambodia Mixed approach of voluntary insurance (CBHIs) and totally subsidized persons by donors (HEFs),
yet no mechanism functioning for formal sector
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Concluding remarks
Taking into account the different stage of social and economic development of the present and the future situation, especially: percentages of those working for the primary sector (farmers, fishermen), percentage of those working for ‘informal’ economy’, percentage of the ‘poor’ who may not be able to afford contributions, what is and will be the most adequate sequence of strategy of extending coverage in a country?
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Substantial government subsidies from taxation seem to be essential for the coverage of the ‘informal’ economy workers and non-workers (Australia, New Zealand, Japan, Korea, Thailand), taking into account low average income of those people, difficulties of administering the targets (registration, income assessments, contribution collections).
How far could be handled through ‘voluntary’ mechanism, taking into account the affordability of low-income earners, the possible no-interest, adverse selections, administration cost and financial sustainability? Should it be considered as a transitory measure?
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How can we guarantee the linkage / coordination / integration of the financing and the administration between national insurance schemes, CBHIs and HEFs?
How can we better redistribute financial resources among schemes (better risk pooling, ensuring equities)?
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