4th Technical Review Meeting for the
Health Policy and Health Finance
Knowledge Hub
The path to universal coverage:
The World Health Report 2010
11 October, Nossal Institute, Melbourne
Martina Pellny, Technical Officer Health Care Financing,
WHO Regional Office for the Western Pacific (WPRO),
DPS, Fiji
WHR 2010: Universal Coverage
 WHR topic based on World Health Assembly Resolution in 2005
The Resolution 58.33 defined “Universal Coverage” as coverage
with: needed health services; financial risk protection; for
everyone.
 The aspiration to attain universal coverage is not new. You find
reference to it in: WHO's constitution-1948; Alma-Ata Declaration-1978;
World Health Report on Primary Health Care-2008 etc
 The resolution also states that universal (health) coverage can
not be achieved without a well-functioning health financing
system
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1.
Three
Dimensions
3.
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2.
1. Dimension: Financial Protection
Millions suffer financial ruin when they use health services:
 Globally around 150 million suffer severe financial
hardship/ catastrophic health expenditures each year.
 100 million are pushed into poverty because they must
pay out-of-pocket at the time they receive health
services.
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1. Dimension: Financial Protection
EMR
im poveris hm ent
AFR
catas trophic
EUR
SEA
AMR
WPR
-
30
60
90
Number of people (million)
Highest burden in Asia: In the WHO WPRO region 80 million people
experience financial catastrophe and 50 million impoverish due to health
payments (half the people worldwide). Source: Equitap
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1. Dimension: Financial Protection
Percentage
Figure 7.Out-of -pocket health expenditure as %
of total health expenditure
80
70
60
50
40
30
20
10
0
2005
2007
Cam
Chn
Lao
Mon
PNG
Phl
Se le cte d WPR countrie s
Source: WPRO Health Financing Review, 2008
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Vtn
2. Dimension: which services are covered?
100
99 M OG
95 V T N
87 V T N
80
82 CA M / M OG
81 M OG
79 M OG
83 V T N
83 V T N
80 V T N
Percentage
76 P HL
60
56 LA O
42 V T N
40
35 P NG
33 LA O
32 LA O
30 LA O
20
20 LA O
18 LA O
17 V T N
14 P NG
0
SBA Early BF EBF BF & CF
NT
Source: CHIPS 2009
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Vit A Measles ORT
ARI
ITN
3.Dimension: who is covered?
Percentage of births attended by skilled health worker
0
20
40
60
80
100
Q1, Q5 and Average - 22
0
10
20
30
Q5
Q1
Average
Source: Latest available DHS for each country (excl. CIS countries)
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40
50
countries
Proposing solutions: the WHR 2010
 The WHR-2010 proposes three interrelated health financing strategic options
for universal coverage:
- Raise sufficient funds for health: More
money for health
- Reduce heavy reliance on direct OOP:
More equity for health.
- Reduce and eliminate inefficient use
of resources: More health for the
money
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Problem 1: Insufficient funds

A set of essential health services focusing on the Millennium
Development Goals would cost on average US$ 44 per capita in
low-income countries in 2009, rising to US$ 60 in 2015
(estimates provided by the HLTF on Innovative International
Financing for Health Systems).

31 low income countries spent less than US$ 35 per person
(2008)

Only 8 have any chance of reaching the required funding from
domestic sources by 2015 - even assuming rapid growth of their
domestic economies.

CAM (30), Laos (24), PNG (29), Solomon Islands (44), Vietnam(46)
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Options for raising more domestic funds for health
 Increase the priority given to health in government budget
allocations
 MoHs often not powerful enough – loose out in budget negotiations
 Ex: MTEF - clear and transparent targets
 Ex: Abuja declaration: African heads of state declared in 2001 to
increase the share of government expenditures going to health to
15% of GGE in 2007, and failed
 Raise revenue for health more efficiently – e.g. increase the
total availability of resources (strong tax base)
 In Indonesia, clear and consistent regulations and a policy of zerotolerance for corruption increased tax yield from 9.9% to 11% of GDP
over four years – with a subsequent increase in health expenditures.
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Options for raising more domestic funds for health

Find new sources of domestic funds e.g.
 "Sin" taxes on tobacco and alcohol: a 50% increase in tobacco tax alone
would yield an additional US$ 1.42 billion - this could increase
government health expenditure by up to 25%.
 Excise tax on unhealthy food – Romania – 20% on foods high in fat, salt,
sugar
 Levy on currency transactions would be feasible in countries with large
markets – e.g. India could raise US$ 370 million per year from a very
small levy (0.005%).
 Levy on remittance transactions - Gabon
 Levy on large/ profitable companies – Australia (mining companies);
Pakistan (pharmaceutical companies), Gabon (mobile ph. companies).
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Problem 2: Heavy reliance on direct OOPs
 The WHR-2010 proposes three interrelated health financing strategic options
for universal coverage:
- Raise sufficient funds for health: More
money for health
- Reduce heavy reliance on direct OOP:
More equity for health.
- Reduce and eliminate inefficient use
of resources: More health for the
money
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Options to reduce the impact of OOPs

Reducing OOPs requires switching to systems of “prepayment” with
subsequent “pooling” of revenues (Prepayment means paying before
illness – and it can take the form of taxation or insurance – Beveridge/
Bismarck/ mix). PREPAYMENT

There seems a minimum level of compulsory prepaid funding that is
necessary to ensure that the poor and vulnerable are covered: ca. 4-6% of
GDP. See WHO WPRO benchmark: “Universal coverage is difficult to
achieve if public financing is less than 5% of GDP”. MINIMUM

Community and micro-insurance can play a useful role in the early stages,
but plans to merge them over time are important - bigger pools are more
financially viable than small community-based pooled funds.
CONSOLIDATE POOLS AND REGULATE
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Options to reduce the impact of OOPs
Options in addition to prepaid and pooled resources to ensure
greater coverage and lower financial barriers:

Free or subsidized services (e.g. through exemptions or
vouchers) for specific groups of people (i.e. the poor) or for
specific health conditions (i.e. child or maternal care).

Subsidized or free insurance contributions for the poor and
vulnerable.

Cash payments to cover for ex. transport costs for the poor.
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Problem 3: Inefficiencies
Ten leading source of inefficiency
1. Medicine: underuse of generics and higher than necessary price.
2. Medicine: use of substandard and counterfeit medicines.
3. Medicine: inappropriate and ineffective use.
4. Products and services: overuse/supply of equipment, diagnostic services and
procedures.
5. Health workers: inappropriate or costly staff mix, unmotivated workers.
6. Health service: inappropriate hospital admission and length of stay.
7. Health service: inappropriate hospital size and low use of infrastructure.
8. Health service: medical errors and suboptimal quality.
9. Health system leakages: waste, corruption and fraud
10. Health intervention: inefficient mix and inappropriate level.
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Options to encourage greater efficiency
For example:
1. Paying providers: move away from fee for service if possible.
Consider results-based payment where good monitoring is
possible etc.
2. Medicines: improve prescribing guidance, training of staff;
incentives for generic substitution; regulate promotional
activities, more public information (irrational use) etc.
3. Health services/ governance: Provide more continuity of care,
monitor hospital performance, improve regulatory capacity
4. Reduce duplication – avoid “fragmentation” with - Funding
channels; - Laboratory systems; - Auditing and monitoring
systems; - Reporting systems including reporting to donors (Aid
effectiveness principles).
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Greater efficiency includes
comprehensive health plans
National
health
plans
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Conclusion

Regardless of the stages of development, each country can improve
their financing systems to maintain or progress towards universal
coverage.

The global community can do more to raise needed funds and
strengthen national financing institutions and capacities to attain
universal coverage.
 Stop introducing more global initiatives with more secretariats at
the international level.
 Buy into the countries national health plans and channel funds
to countries in ways that build domestic financing capacities and
institutions, rather than bypassing weak systems – e.g. fund
Sector Wide Approaches, General Budget Support etc
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Thank you
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