Transcript HEALTH SYSTEMS IN LDCs CURRENT SITUATION

Public Health Practice III:
FINANCING PUBLIC
HEALTH REFORM
Thomas E. Novotny MD MPH
University of California San Francisco
Institute for Global Health
3 August 2004
Learning objectives

Establish context for health systems

Provide general description of existing
healthcare systems
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Describe role of World Bank in policy
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Present current World Bank policy
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Identify issues with proposed direction
Populations and disease
 Health
status indicators
 Epidemiologic
 Demographic
 Poverty
transition
transition
as root cause
Declaration of Alma Ata (1978)

Definition of health
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State of complete physical, mental and social
wellbeing
Not merely absence of infirmity or disease
Fundamentally human right
Attainment of highest possible level is
worldwide priority and common concern of all
countries
Primary care

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
Essential health care
Universally accessible
Affordable cost
Primary health care defined
Addresses main health problems in
community
 Provides promotive, preventive, curative
and rehabilitative services
 Broad definition to include proper
nutrition, safe water, basic sanitation,
prevention and control of communicable
diseases, provision of essential drugs
 Promotes community self-reliance using
local and national resources
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Elements of Health Systems
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Production of resources (people,
supplies, facilities, knowledge)
Organization of programs (government,
private providers, NGOs)
Economic support mechanisms (source
of funds)
Management methods (planning,
administration, monitoring and evaluation)
Delivery of services
(preventive/curative,
primary/secondary/tertiary, public health)
Economic Dimensions of Health Systems
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Source of payment
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How services provided
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Voluntary (private insurance, user fees)
Compulsory (taxes, social insurance)
Direct ownership by government
Contractual arrangements
Private providers paid directly by consumer
How services paid

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Prospectively – provider assumes risk
Retrospectively – costs reimbursed
Four key actors
 Government
 Population
 Financing
 Providers
to be served
agents
Four key functions
 Regulation
 Financing
 Resource
allocation
 Providing
services
Current situation
 Government
as largest provider

universal access

high spending on hospitals

highly centralized

bureaucratic

fluctuating budgets

poor motivation
ISSUES
 Market
model not panacea
 Ability
of Ministry of Health to lead
transformation
 Lack
of management capacity to
implement changes
Current situation
 Changing
 Half

public or private insurance
of spending “out-of-pocket”
Mainly pharmaceuticals
Current situation
 Limited
power of Ministry of Health
 Private
provider = quality provider
 Lack
of access for certain populations
World Bank as opinion leader
 Health
is addressed through
economic development
 Burden
of disease translates into
economic terms (DALYs)
World Bank as opinion leader
 Government
and private sector have
separate roles

prevention/public health

essential package of services

curative care
World Bank as opinion leader
 Health
system barriers to progress

misallocation

inequity

inefficiency

exploding costs
Why health sector reform?
 Recognition
population
 Part
of need for healthy
of overall lending packages
 Enhancing
services
the performance of health
Key concepts for health sector reform
 Accessibility
 Efficiency
 Effectiveness
 Quality
 Consumer
satisfaction
Accessibility
 Equitable
 Reduced
barriers
Effectiveness
 Spend
money in the right place –
most benefit to most people
 Improve
clinical outcomes
 Increase
accountability
Efficiency
 Maximize
 Increase
 Provide
the money spent
management capacity
incentives
Quality
 Incentives
for change
 Information
widely available
 Accreditation
processes
Consumer satisfaction
 Increased
 Informed
 Input
choice
choice
to services provided
POLICY SOLUTIONS
 Enable
households to improve health
 Improve
health
 Promote
government investments in
diversity and competition in
financing and delivery
POLICY ONE:
Enable households
 Economic
growth policies that
benefit poor
 Expand investment in schooling
 Promote human rights
POLICY TWO:
Improve government investment
 Reduce
spending on tertiary and
specialty care with low cost benefit
 Finance
and implement package of
public health interventions
POLICY TWO:
Improve government investment
 Finance
and ensure delivery of
package of essential clinical services
 Improve
management through
decentralization and budget
autonomy
POLICY THREE:
Promote diversity and competition
 Government
provides public health
and essential services
 Private
insurance for clinical services
outside essential package
POLICY THREE:
Promote diversity and competition
 Encourage
privatization of all clinical
services
 Produce
information on provider
performance
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