Health care financing in the Asia
Pacific region
A paper by Dan Whitaker, Veronica Walford for the
HLSP Institute - a member of Mott MacDonald - and
Benedict David, DFAT. Presented by Jackie Mundy,
Health Resource Facility for Australia’s aid program
The Health Resource Facility is an Australian Government, DFAT funded initiative managed by Mott MacDonald
(Mott MacDonald Australia Pty Limited) in association with IDSS
Our paper
• Four categories for 30 selected countries in the
region: low income; middle income; small island;
and fragile states
• Desk-based literature review and key informant
interviews
• Analysis:
– Socio-economic, demographic and disease burden
trends
– Trends in domestic and donor financing for health
– Implications of these trends for donors and partners
Share of population living on less
than $1.25/day (inflation-adjusted) based on data from Sumner 2012
80
70
60
50
1990
40
2008
30
20
10
0
india
china
bangladesh
indonesia
philippines
vietnam
nepal
Demographic shifts
•
•
•
•
Population growth slowing, fall in fertility rates
Life expectancy increasing, more older people
= Demographic Transition
‘Window of opportunity’ is now - large working
age population supporting smaller elderly
population
• BUT this will change ….
Ratio of over-65s to 15-64 year olds
in Focus countries
Epidemiological shifts
• Socio-economic and demographic trends
influence burden of disease
• Reduced communicable diseases, strong rise in
non communicable diseases (NCDs)
• Changing disease pattern – needs shift in
priorities and health services offered
Top 5 causes of death and trend in share
of mortality in 4 focus countries, 2010
(measured in years of life lost YLL)
Country
Indonesia
Cause of death
Stroke
Tuberculosis
Road injury
Diarrheal diseases
Ischaemic heart disease
Cambodia Lower respiratory infection
Ischaemic heart disease
Stroke
Preterm birth complications
Congenital abnormalities
PNG
Lower respiratory infection
Diabetes
Diarrheal diseases
Tuberculosis
HIV/AIDS
Fiji
Ischaemic heart disease
Diabetes
Stroke
Lower respiratory infection
Preterm birth complications
% of total YLL
NCD
CMNN
injuries
CMNN
NCD
CMNN
NCD
NCD
CMNN
NCD
CMNN
NCD
CMNN
CMNN
CMNN
NCD
NCD
NCD
CMNN
CMNN
11.8
10.6
6.0
5.5
5.2
10.1
7.4
6.3
6.0
4.6
16.3
4.7
4.1
3.3
2.9
16.2
11.0
5.8
5.6
4.4
% change in YLL
1990-2010
76
-6
35
-42
86
-61
80
63
-32
-41
-21
121
-38
11
2,791
66
265
-45
-28
-18
Legend: YLL: years of life lost, takes into account age at death.
CMNN: communicable, maternal, neonatal and nutritional; NCD: non-communicable diseases; : injuries.
Source: Global Burden of Disease 2010, IHME 2013.
Time of opportunity ?
• Demographical and epidemiological shifts need
big changes in the way health is delivered and
financed
• For now, more workers means more tax to pay
for health care
• Many countries rolling out social health
insurance with moves towards universal health
coverage
• Sustainable once more elderly people and
relatively less workers paying tax?
Forecasts of annual spending on
citizens aged over 65 years
% of population
over 65 years
Health spend per
capita over 65s
Estimated total health spending
required for population over 65
years
2011
%
2041
%
2011
$
2041
$
2011
$m
2021
$m
2031
$m
2041
$m
Indonesia
6.3%
15.6%
163
13,837
2,460
15,600
Cambodia
3.8%
9.0%
89
719
48
144
476
1,358
PNG
3.6%
8.6%
138
2,124
34
122
455
1,718
Fiji
5.2%
13.8%
290
2,332
13
42
128
322
101,935 642,067
Source: Author’s calculations; WHO NHA data; US Census.
All sums are in constant $(2011) and would require inflation adjustment to reach current $ for the years in question.
Health care financing trends, 20012011 in focus countries
Total health expenditure / GDP
Public sector share / Total health
expenditure
Health share in all government spending
SHI share in government health spending
OOP share of private health spending
Change in per capita total health spend
(ppp basis)
Change in per capita government health
spend
Indonesia Cambodia
+
Static
+
+
Fiji
+
-
PNG
-
+
+
static
+ (2.1x)
static
n/a
+ (1.7x)
static
n/a
static
+ (1.7x)
n/a
static
(1.1x)
+ (2.3x)
+ (2.7x)
+ (1.5x)
(1.0x)
Source: NHAs. Note: + = increase; - = decrease; static = relatively unchanged
The effect of major health reforms on
OOP
Country (scheme)
Indonesia (SHI: BPJS)
Philippines (SHI:
PhilHealth)
Vietnam (SHI: VSS)
India (SHI: RSBY)
Thailand (SHI/tax: UC)
Cambodia (tax/donor:
HEFs)
%
Scope of benefits OOP as %
population
of THE,
enrolled*
2011
63%
Comprehensive
38%
In-patient, with
76%
54%
out-patient for poor
42%
Comprehensive
58%
In patient, pilot
8%
61%
out-patient
95%
Comprehensive
14%
In patient, pilot
17%
40%
out-patient
Source: own calculations using NHA and Lagomarsino (2012) for enrollment and benefit data.
* 2012 or most recent data
Change in OOP
since reform
(date)
-2% (2004)
+4% (1995)
-6% (2002)
-2% (2008)
-19% (2001)
-22% (2000)
Trends in DAH, Asia-Pacific
countries, 2001-2010, US$ (millions)
2000
1800
1600
1400
1200
E Asia and Pacific
1000
South Asia
800
600
400
200
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Allocations of ODA by purpose, by
country category, 2010
disbursements
Fragile states
LICs
MICs
Island states
Asia Pacific
region
Source: WHO (2012)
Health policy,
administrative,
management
23%
13%
21%
54%
HIV, TB,
malaria
(MDG 6)
21%
41%
48%
33%
Other health
purposes
41%
33%
22%
13%
Reproductive
health, family
planning
14%
12%
9%
0%
22%
41%
27%
10%
Roles for aid / donors
• Review aid allocation to target where most needed – eg
Pacific islands with little scope for income growth;
neglected groups within countries; emerging
epidemiology
• Enable TA and regional experience sharing to support
reforms to health financing & health systems
• Better coordination and partnerships
• Each donor to identify comparative advantage and how
to maximise its use
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The Health Resource Facility is an Australian Government, DFAT funded initiative managed by Mott MacDonald
(Mott MacDonald Australia Pty Limited) in association with IDSS
Share of government health
spending that is via social insurance,
2001 and 2011
Source: WHO NHA data. Note that SHI expenditure may be rising in absolute terms even as it declines as share of
government spending, and that national classifications of funding may differ.