GETTING OUR SYSTEMS RIGHT
to secure
UNIVERSAL HEALTH COVERAGE
Presentation to the 10th Caribbean Health Financing Initiative Conference
Raphael D. Barrett
Providenciales
October 2015
Turks & Caicos Islands
WHO PUBLICATIONS ON UHC

World Health Report 2010
"Health Systems Financing: A path to universal coverage“

World Health Report 2013
“Research for Universal Health Coverage”

PAHO/WB Report 2015
“Toward Universal Health Coverage and Equity in Latin
America and the Caribbean: Evidence from Selected
Countries”
WHAT ARE THE KEY PRINCIPLES,
CHARACTERISTICS, INDICATORS OF A
HEALTH FINANCING SYSTEM
WHICH REFLECTS
UNIVERSAL HEALTH COVERAGE?
UNIVERSAL HEALTH COVERAGE – WHO
Universal Health Coverage is firmly based on

the WHO constitution of 1948 declaring health a
fundamental human right

the Health for All agenda set by the Alma-Ata declaration
in 1978
Equity is paramount - tracking progress not just across the
national population but within different groups (e.g. income,
sex, age, place of residence, migrant status and ethnic origin)
The goal of Universal Health Coverage is to ensure that all
people obtain the health services they need without suffering
financial hardship when paying for them
UHC – WHO Fact Sheet N°395 September 2014

UHC means that all people receive the health services
they need without suffering financial hardship when
paying for them.

UHC interventions must address the most important
causes of disease and mortality whilst delivering the
full spectrum of essential, quality health services to
improve the health of those receiving the services.

Health Financing mechanisms are a critical factor e.g.
pooling funds to spread financial risk across the
population, cross subsidies - rich/poor, healthy/sick increased access.
UHC – WHO Fact Sheet N°395 September 2014

UHC not achieved overnight; all countries can take actions
to maintain gains made and move more rapidly towards it.

As Governments find it increasingly difficult to meet the
increasing health service costs and ever growing needs of
their populations, key factors in prioritising health services
include

epidemiological context,

health systems,

level of socioeconomic development,

people’s expectations.
MYTHS about Universal Health Coverage

UHC is not just health financing, but covers all components of the
health system to be successful

UHC is not only about assuring a minimum package of health
services, but also about assuring a progressive expansion of
coverage of health services and financial risk protection.

UHC does not mean free coverage for all possible health
interventions, regardless of the cost; no country can provide all
services free of charge on a sustainable basis.
UHC is much more than just health
taking steps towards UHC means steps towards equity,
development priorities, social inclusion and cohesion
ACHIEVING Universal Health Coverage

A strong, efficient, well-run health system that meets
priority health needs through people-centred integrated care

Affordability – a system for financing health services so
people do not suffer financial hardship when using them.

Access to essential medicines and technologies to diagnose
and treat health problems.

A sufficient capacity of well-trained, motivated health
workers to provide the services to meet patients’ needs
based on the best available evidence.
The IMPACT of Universal Health Coverage

Access to health services enables people to be more
productive and active contributors to their families and
communities.

Financial Risk Protection prevents people being pushed
into poverty when they have OOP for health services.
UHC is a critical component of sustainable development,
poverty reduction and any effort to reduce social inequities
CARICOM: Nassau declaration of 2001– the Health of the region is
the Wealth of the region
WHO:
Universal Coverage is the hallmark of a government’s
commitment to improve the wellbeing of all its citizens
HEALTH FINANCING FOR UHC
Given the objectives - Access, Financial Risk Protection health financing mechanisms suitable for UHC must include

Encouraging and facilitating the basic principles of
insurance
Prepayment – so persons do not faced the full cost of an event
when it occurs but have ‘saved for the rainy day’
 Risk sharing – pooled funds allowing persons to share their risk


Mandatory participation
Government intervention, directly or indirectly, is necessary
 To ensure the largest insurance pool – the total population
 To avoid selective participation – persons staying out until they
need services
TO WHAT EXTENT ARE
CARIBBEAN HEALTH FINANCING SYSTEMS
GETTING CLOSER TO OR FARTHER FROM
UNIVERSAL HEALTH COVERAGE?
PROVIDING & FINANCING Caribbean Health Services
Services
Public health
Provision/Agencies
Public
Financing
Taxes/budget
Ambulatory care
(GPs, Specialists)
Public, Private
OOP; taxes-budget, insurance, NGOs
Inpatient Care
Public, Private
Taxes-budget, OOP, insurance, grants
Drugs & Diagnostics
Public, Private
OOP, insurance, taxes-budget, NHF
Overseas care
Public, Private
Insurance, OOP, taxes-budget, grants
Training-Research
Public, Private
Taxes-budget, OOP, grants
NOTE: All countries have a high level of Out-Of-Pocket payments (avg = 28%)
CARIBBEAN HEALTH FINANCING SYSTEMS
Table was prepared by Dr Stanley Lalta, 2015 (source: WHO/WB, 2012)
Govt Tax/Budget (>60%)
SHI (>60%)
Hybrid - Govt/SHI
1
Anguilla*
Bermuda*
Antigua
2
Barbados
Cayman Is*
Bahamas
3
Belize
Turks & Caicos Is*
Haiti
4
Dominica
Aruba*
Jamaica
5
Grenada
Bonaire-Saba-Statia*
Surinam
6
Guyana
Curacao*
Trinidad
7
Montserrat*
St Maarten*
Virgin Is. (UK)*
8
St Kitts
9
St Lucia
10 St Vincent
* Data from country papers at Caribbean Health Financing Conference)
HEALTH FINANCING PATTERNS IN THE CARIBBEAN
Caribbean Total Health Expenditure (THE)
(WHO/WB/Other..2012 database)
 Average THE = 6% GDP
 Average per capita expenditure US$600
 Public spending – up to 66% thru taxes/budget funds and
compulsory SHI in some countries
 Private spending – typically 32% of THE thru direct payments,
private insurance and NGOs
 High OOP - average 75% of private spending; 25% of THE
 Low external support - <2% (except Haiti)
HEALTH SERVICE PROVISION IN THE CARIBBEAN
Health Services are provided by a mix of Public & Private
facilities
 Public sector - dominant in public health, inpatient services,
research/training
 Private sector - dominant in ambulatory care, drugs &
diagnostics and overseas care for critical and complex cases
Patients utilise both facilities with noticeable tiers:
d more low income groups at public facilities;
d middle and high income groups at private facilities;
d very high income and insured persons at overseas facilities.
CARIBBEAN INITIATIVES TO IMPROVE HEALTH SERVICES
Examples of initiatives taken to expand and improve access,
coverage and service provision of national health systems
Antigua & Barbuda Medical Benefits Scheme
Barbados
Aruba
Curacao
Sint Maarten
Jamaica
Belize
Barbados Drug Scheme
AZV [Social Health Insurance]
National Health Plan
AZV [Social Health Insurance]
1972 Medical care - contributors
1980 Specific drugs; conditions - citizens
Specific drugs; conditions - contributors
1994 Specific drugs; conditions - contributors
Specific drugs; conditions - contributors
Jamaica Drugs for the Elderly Programme 1996 Specific drugs; conditions - residents
National Health Fund
2003
National Health Insurance
Trinidad & Tobago Chronic Disease Assistance Programme
2001 Specific drugs; conditions - contributors
2004 Specific drugs; conditions - residents
St. Lucia
Universal Health Care
2005 Medical care - residents
Bahamas
National Prescription Drug Plan
2010 Specific drugs; conditions – contributors
National Health Insurance
2010 Specific drugs; conditions – contributors
Turks & Caicos
NCCD – 54%
Injuries – 11%
Cardio – 52%
Communicable – 20%
Other – 15%
Cancer – 15%
NCCD – 74%
Injuries – 10%
Cardio – 36%
Communicable – 14%
Other – 2%
Cancer – 17%
WHAT REFORMS/MEASURES SHOULD BE
IMPLEMENTED TO ADDRESS GAPS IN
HEALTH FINANCING SYSTEMS
FOR UNIVERSAL HEALTH COVERAGE?
HOW TO MANAGE THE
POLITICAL/STAKEHOLDER INTERESTS WHICH
INFLUENCE SUCCESS?
ISSUES FOR UHC IN THE CARIBBEAN


Structural

Small populations and economies vulnerable to natural
disasters and global economic shocks

High dependence on tourism subjecting population to
exposure to travel-borne diseases

Growing inter-island population movement exposing some
states to high migrant influx
Technological

low economies of scale make the purchase of technologies
very expensive, per capita

Due to small populations utilisation of complex, expensive
services low making it difficult to retain trained staff
ISSUES FOR UHC IN THE CARIBBEAN


Demographic and Social

aging population; increased migration of working age
population

growing health expectations – ready exposure to systems and
services available elsewhere
Epidemiological

dominant CNCD (1 in 3 persons)

infectious diseases – HIV, re-emerging conditions e.g. TB,
Malaria
ISSUES FOR UHC IN THE CARIBBEAN

Macroeconomic and Fiscal





Low economic growth rates and recession
Fiscal constraints – budget/current account deficits; high debt burden
Double digit unemployment and poverty rates
Eligibility for external funds – many countries now classified as
‘middle income’
Financing

Has to be mandatory as solidarity is low

How to increase finances for health – taxes, contributions

Better management and utilisation of pooled funds

Better integration with private health insurance
ISSUES FOR UHC IN THE CARIBBEAN

Operational



Improper use of Secondary Emergency Services Primary Care
facilities
Leakage of supplies, medicines, labour
Issues implementing results-based provider payment systems:



Private systems tend to favour cost based fee-for-service
Public systems tend to favour inputs-based budgets
Politics

Greater demands for complicated/expensive services

Should healthcare be removed from profit motive if it is designated
a human right?
ISSUES FOR UHC IN THE CARIBBEAN

Coverage


Most countries seek to restrict coverage to citizens due to the
cost of providing for immigrants and the legal implications
Concerns re non-citizens

Have little or no political clout as they often do not have a vote

Are seen as an immigration/security problem rather than the
economic contributors they are, e.g. low paid jobs sometimes
with mandatory statutory contributions

Size in relation to the “belonger” population: Bahamas, TCI
ISSUES FOR UHC IN THE CARIBBEAN

Removal of user fees – “free health care”

‘free health care’ often results in lower quality/standards of
services due to irrational demand

Meets the UHC standard for access but is not equitable if it
reduces revenues from those who can afford some payment

has been difficult to counter politically – ‘freeness mentality’

has resulted in less financial resources for the sector and
greater demands on the system

less rational use of services with patients bypassing primary
health services in favour of secondary facilities
BAHAMAS NEWS EXTRACTS
“The Bahamas Insurance Association has
always been committed to implement UHC
in a manner that is affordable, sustainable
and least disruptive to the industry and
economy at large…
…the Prime Minister had indicated that NHI
will be the ‘single biggest development’ in
the Bahamas, post-independence…
…we do not want to fight with the
Government on a progressive social
initiative that is designed to serve the best
interest of the Bahamian people…
…after all, we all support the principle of
universal healthcare.”
Private sector stakeholders
believe PricewaterhouseCoopers
has advised the Government to
take a completely different
approach to healthcare reform
and adopt an ObamaCare-style
plan…
…rather than go with an allencompassing NHI model…
coverage would be offered
through private insurers, with
subsidies for those who can’t
afford the premiums.”
HEALTH FINANCING FOR UHC
1. Need to understand that health financing being a national issue does
not imply or mean 100% government financing
2. The government’s role should be coordinator, facilitator and subsidiser
for specific groupings determined, preferably, economically
3. Establishing pooled funds enhances the insurance function by spreading
risks and contributions over the largest pool – the total population
4. There needs to be better administration of pooled funds so that they
are autonomous in the collection and management of their finances
5. More use of dedicated taxation for health – ‘sin taxes’, visitor health fee
6. Benefit structures need to be patient centric – economically enabling
patients thereby giving them choice
T
H
A
N
K
Y
O
U