Health Reform,
Health Financing, and
Population Health
Dominic S. Haazen,
Sr. Health Specialist,
The World Bank
Riga, Latvia
Presentation Outline
Program of Action elements relevant
to this discussion
Key health reform interventions in
the countries in transition
Developments in health financing and
payment systems
Recent developments in HIV/AIDS
Implications for population health
Program of Action – ICPD 1994
universal access - primary health
care
universal access – comprehensive
reproductive health services
including family planning
reductions in infant, child and
maternal morbidity and mortality
increased life expectancy
Accomplishments – ICPD+5 1999
population concerns integrated into
development strategies in many countries
mortality in most countries continued to fall
broad-based definition of reproductive
health increasingly accepted
steps being taken to provide comprehensive
services in many countries
increasing emphasis on quality of care
rising use of family planning methods
greater accessibility to family planning
Unfinished Agenda – ICPD+5 1999
Still unacceptably high mortality/morbidity
HIV/AIDS
Infectious diseases, such as tuberculosis
Maternal mortality/morbidity
Adult NCD mortality for countries with
economies in transition , especially among men
Adolescents particularly vulnerable to
reproductive and sexual risks.
Lack of access by many to reproductive
health information and services
Constraints/Needs – ICPD+5 1999
financial, institutional, HR constraints
greater political commitment needed
national capacity must be developed, but
increased international assistance is needed
more domestic resources must be allocated
effective priority-setting within each national
context is an critical factor
integrated approach: policy design, planning,
service delivery, research and monitoring
Action Items – ICPD+5 1999
ensure social safety nets are
implemented
strengthen specific health programs:
infant/child health programs that improve
prenatal care and nutrition,
maternal health services,
quality family-planning services
efforts to prevent transmission of
HIV/AIDS and other sexually
transmitted diseases;
Action Items – ICPD+5 1999
strengthen health-care systems to
respond to priority demands
ensure resources are focused on the
health needs of people in poverty
develop special policies and health
promotion programs to address rising or
stagnating mortality levels
strengthen national information
systems to produce reliable statistics in
a timely manner.
Key Health Reforms – ECA Region
Introduction of primary health care
Decentralization of health facilities
Health insurance (various models)
Provider payment reforms
Rationalization of health services
Hospitals, EMS, PHC, specialists
Introduction of health promotion and
prevention approaches, strategies
Adoption of DOTS
WB Supported Interventions – 1991-2001
% of Total Loans/Credits
Pharmaceutical Policy
Primary Health Care
25%
20%
Hospitals
15%
Human Resource Dev.
10%
5%
TB and AIDS
0%
Quality Improvement
HMIS
Health
Health Financing
Reform/Insurance
Health Policy Reform
Promotion/Disease
Control
Health Financing Dimensions
Revenue raising – amount/method
Pooling of funds
Resource allocation
Coverage/benefit package
Out of pocket payments
Purchasing methods
Health System Financing & Population Links
Health care
Provision of services
User charges
Allocation mechanisms
(provider payment)
Coverage
Choice?
Allocation mechanisms
Coverage
Pooling of funds
Choice?
Allocation mechanisms
Funding
flows
Benefit
flows
em e
Entitl
nt?
Collection of funds
Contributions
Individuals
Purchasing of services
Revenue Raising Methods
payroll tax emerged as a standard source
of health care financing
14 countries have payroll taxes: 9 as main
financing mechanism, 5 as complementary
contribution rates range from 2% in
Kyrgzstan to 18% in Croatia
7 countries rely primarily on taxation
Out-of-pocket costs range from less than
20% in Slovenia and Croatia to over 80% in
Georgia and Azerbaijan
Out of Pocket Payments in ECA
Czech
Slovenia
Estonia
Croatia
Hungary
Slovakia
Latvia
Russia
Poland
Romania
Albania
Kazakh.
Moldova
Public
Kyrgyz
OOP
Azer.
Georgia
0%
20%
40%
60%
80%
100%
Out of Pocket Payments - Impact
OOP payments affect treatment choice
riskier interventions such as surgery
require larger payments
Services that may be seen as discretionary
(pre- and post-natal care), may be avoided
Quality of care and waiting times may
depend on ability to pay
Undermines universality of publicly
financed health programs
Revenue Raising Capacity …
12,000
35
GDP/Capita ($PPP)
10,000
Taxes/Capita ($PPP)
30
Taxes % GDP
25
8,000
20
6,000
15
4,000
10
2,000
5
0
0
CIS-7
Other CIS
South-East
Europe
Turkey
Russian
EU
Europe &
Federation
Accession
Central Asia
… and Impact on Health Spending
800
700
600
6
Public Health/Capita ($PPP)
Total Health/Capita ($PPP)
5
Public Health as % GDP
4
500
400
3
300
2
200
1
100
0
0
CIS-7
Other CIS
South-East
Europe
Turkey
Russian
EU
Federation
Accession
Europe &
Central Asia
Public Health Spending vs. GDP
Coverage – “Basket of Services”
Many/most countries have attempted to
define, but with limited success
14 studies funded through WB alone
e.g., Armenia - universal coverage only for
primary/emergency services; some secondary
services available only for the poor
Even when defined, non-poor often benefit
disproportionately
Definition of “emergency” in Armenia
Urban-rural disparities in access
Payment Methods – Physician Services
W. Europe
All
Hospital
O/P
Specialist
PHC
Salary
Finland
Portugal
England
Ireland
Italy
Denmark
Germany
England
Ireland
Italy
Sweden
Fee-for-service
France
Belgium
Germany
Sweden
Germany
Capitation
Capitation/FFS
Capitation/Salary
Flat Rate/FFS
England
Ireland
Denmark
Spain
Austria
Italy
Payment Methods – Physician Services
ECA Region
Salary
Fee-for-service
FFS/Volume limit
All
Hospital
O/P
Specialist
MD, BY,
TM, TJ,
AZ
SI, AL,
CZ, AM,
RO, BG
SI, AL
GE, LV
LV, LT, PL,
RO, BG
CZ
Capitation
Capitation/FFS
PHC
AL, PL, HU
GE
CZ, RO, BG,
EE, SI, SK
Capitation/Bonus
GE, EE, LT
Capitation/Fundholding
LV
Payment Methods – Inpatient Care
14
Line Item
Number of Countries
12
Per Diem
10
8
Per Case
6
Global Budget
4
Global Budget
with DRG/CaseMix Adjuster
2
0
Western Europe
ECA (existing)
ECA (in Dev't)
Payment Methods and Incentives
Mechanisms
Incentives for Provider Behavior
Prevention
Line Item Budget
Fee-for-Service
Per Diem
Per Case (e.g., DRG)
Global Budget
Capitation
Service
Delivery
Cost
Containment
Provider Payment Methods - Impact
Any one method by itself does not
satisfy all objectives
Additional incentives are needed to
address those inherent in selected
approach
More sophisticated methods often
require information systems that may
not (yet) be available in transition
countries
HIV infections newly diagnosed per million population
1994-2002, selected countries, eastern Europe
Cases
per million
1000
800
Estonia
600
Update at 30 June 2003
400
Russian Federation
Latvia
Ukraine
Lithuania
Belarus
200
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year of report
EuroHIV
HIV infections newly diagnosed per million population
1994-2002, selected countries, eastern Europe
Cases
per million
100
Belarus
80
60
Moldova
Kazakhstan
Uzbekistan
Kyrgyzstan
Georgia
Azerbaijan
Armenia
Tajikistan
Update at 30 June 2003
40
20
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year of report
EuroHIV
HIV infections newly diagnosed per million population
1994-2002, selected countries, central Europe
40
Cases
per million
30
Romania
Poland
Slovenia
Hungary
Serbia & Montenegro
Czech Republic
Slovakia
Update at 30 June 2003
20
10
0
1994
1995
1996
1997
1998
1999
Year of report
2000
2001
2002
EuroHIV
HIV/AIDS Regional Support Strategy
Raising political and social commitment
Generating/using essential information
Estimating the economic and social impact
Improving surveillance
Maximizing value for money
Estimating resource requirements
Prevention of TB and HIV/AIDS
Harm reduction, focus: CSW, IDU, prisons
Sustainable, high quality care
Facilitating large-scale implementation
Implications for Population Health
Unfinished rationalization agenda:
Misallocation of resources
Service quality (incl. reproductive health)
Under-funding of PHC and prevention
Limited public funding in many countries
Reproductive health must compete
Challenge to ensure access for poor/rural
Provider payment systems incentives
Must encourage RH related activities
Implications for Population Health
Primary health care “immature”
Obs./Gyn. specialists still do most RH
Public confidence in PHC abilities
Information systems tell us little about
what is going on (“known unknowns”?)
Amount of ante-natal/post-natal care
Other reproductive health activities
Hospitalization (ALOS, C-section, comp.)
Disease surveillance
Thank you!!
Dominic S. Haazen,
Sr. Health Specialist,
The World Bank
Riga, Latvia
dhaazen@worldbank.org