UNIVERSAL HEALTH
COVERAGE
UP Devkota
HISTORY
•
Socialist movement 1830’s
•
Royal commission on Operation of the Poor Laws 1832
•
Carl Marx (Das Kapital 1867)
•
Liberal challenged by Labour (1906) - Welfare reforms
•
•
National Insurance Act 1911 - David Lloyd George
Post – First World War
Serious social reform to avert communist revolt
THE BEVERIDGE REPORT 1942
• Giant Evils in society –
Squalor, ignorance, want, idleness and disease
• Recommendation
Flat compulsory national insurance scheme for
Healthcare, unemployment and retirement benefit
• Caution
Misuse of unemployment benefit
Inherent human laziness
THE NATIONAL HEALTH SERVICE
• Labour Party victory 1945 (NHS act 1946/47/48)
• Implementation 5th July 1948 (Aneurin Bevan)
• Welfare state – “Care from the cradle to the grave”
• Funding – General taxation + National insurance
• All municipal and charitable hospitals nationalised
Could war impoverished Britain afford it?
•
The classic welfare state 1945-1980
GOVERNMENT EXPENDITURE
United Kingdom
Nepal
88
(13.06%)
86.03
(16.63%)
33.52
(6.48%)
313.83
(60.67%)
239
(35.46%)
119
(17.66%)
55
(10.63%)
28.86
(5.58%)
Education, Rs. 86.03 bn
Health, Rs. 33.52 bn
Social security and pension, Rs. 55.00 bn
38
(5.64%)
Education, £ 88bn
Social protection, £ 190bn
Others, £ 239bn
190
(28.19%)
Health, £ 119bn
Defence, £ 38bn
SOCIAL WELFARE EXPENDITURE UK
2011-12
Benefit
State pension
Housing Benefit
Disability Living Allowance
Pension Credit
Income Support
Rent rebates
Attendance Allowance
Jobseeker’s Allowance
Incapacity Benefit
Council Tax Benefit
Other uncategorized expenditure
Employment and Support Allowance
Statutory Sick/Maternity pay
Social Fund
Carer’s Allowance
Financial Assistance Scheme
TOTAL
Expenditure (£bn)
£74.2
£16.9
£12.6
£8.1
£6.9
£5.5
£5.3
£4.9
£4.9
£4.8
£4.7
£3.6
£2.5
£2.4
£1.7
£1.2
£160.2
NEPALESE REALITIES IN 2002
• GDP per capita $261
• Budget on health < 5% of the total ($2.30 per person).
• Total health expenditure
62.5% out of pocket
16.8% public expenditure
9% EDPs
HEALTH SECTOR FINANCING
Requirement
Total National Spending
Tertiary
Secondary
Primary Health Care Service
12 – 36 US $ / head
N
O
M
O
N
E
Y
7
1.5
3
Pocket
EDP
Govt
THE WAY FORWARD…
• EHCS- government’s responsibility
• Secondary/tertiary care health insurance
FEASIBILITY WORK FOR HEALTH
INSURANCE
• Positive attributes
•
Risk sharing culture- guthi, parma etc
•
Solidarity deep rooted in culture
• Health benefit payout NRs 1.2 billion
• Out of pocket spending outside the country NRs 2.3
billion
POPULATION EMPLOYMENT
STATUS 2002
25%
68%
7%
Private formal
Public formal
Self employed
PREPARATORY WORK
• MoH invested on HR training
• Experts from DFID, ILO, WHO to help
• Invested on improving secondary and tertiary care
• Health Sector Reform Strategy
• Established health economics and financing unit
MAJOR FINDINGS AND RECOMMENDATIONS
(ANDREW GREEN)
• Strong political commitment but volatile political stability
• Micro economic condition not conducive to nationwide social
health insurance
• Formal sector (32%) too small to pool risks
• Unwillingness of Government employees (7%) to part with
Medical Benefit Savings
• Prepaid and community health insurance could be piloted and
scaled up
FACILITATION AND IMPLEMENTATION
• Orientation of insurance companies on health insurance
• Requested Bima Sansthan to regulate schemes
• Private companies requested to offer benefit packages
NO TAKERS!
MOH WENT ALONE…..
• Established Insurance Committees to split the
provider and purchaser’s role at HF
• Chose Tikapur, Chandra Nigahpur, Mangalbare,
Dumkauli and Katari for piloting
• Paid the insurance premium for the defined
population
BENEFIT PACKAGE
Scheme
Medicine Diagnosis
Hospitalisation
Transportation
Total
Mangalabare
PHC
(with
referral)
In-patient:
NRs.
3,000;
Outpatient:
NRs.
1,000
Diagnosis:
NRs. 5000;
(50%
copayment in
CT Scan and
Endoscope)
Bed
charge
:NRs.1000;
Operation:
NRs.4000;
operation material:
NRs.1000;
ICU:
NRs. 4000
NRs.1000 way to
facility only.
NRs. 20,000 for
individual
and
NRs.
120,000
for whole family
members.
Mangalabare
PHC (without
referral)
NRs.
3,000
Diagnosis:
NRs. 3000;
(80%
copayment in
CT Scan and
Endoscope)
NRs. 500 one way
for specific VDC
depending upon
case.
NRs. 6,000 per
person.
PREMIUM
Scheme
Category
Amount of premium
Mangalabare PHC
Referral
1400 for a family up to 6
Non referral
600 for a family up to 6
General
700 + 50 for each additional member
Referral
1800 + 200 for each additional member
Dumkauli PHC
IMPACT
• Service utilization increased three folds
• More poor and marginalised (10% Dalits and 41%
Disadvantaged Janajati) were benefitted by the
schemes in compared to private (2% Dalits and 36%
Janajati)
• Cost recovery rate increased to 60% in 2006.
• Governance and accountability of health facilities
improved
RISKS & CHALLENGES AHEAD
• Moral hazard (providers and users) and
• Adverse selection (more sick persons enrolled).
• Potential fiduciary risks
• Quality of care at the public health facility
• Intimidating growth of private sector
• Poor financial governance
Thank You