The Health Resource Facility is an Australian Government, DFAT funded initiative managed by Mott MacDonald (Mott MacDonald Australia Pty Limited) in association with IDSS 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 Health care financing in the Asia Pacific region

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

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 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)

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%16313,8372,46015,600101,935642,067 Cambodia 3.8%9.0% ,358 PNG 3.6%8.6%1382, ,718 Fiji 5.2%13.8%2902, 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, in focus countries IndonesiaCambodiaFijiPNG Total health expenditure / GDP+Static+- Public sector share / Total health expenditure ++-- Health share in all government spending+static - SHI share in government health spending+n/a OOP share of private health spendingstatic- Change in per capita total health spend (ppp basis) + (2.1x)+ (1.7x) (1.1x) Change in per capita government health spend + (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)% population enrolled* Scope of benefitsOOP as % of THE, 2011 Change in OOP since reform (date) Indonesia (SHI: BPJS) 63% Comprehensive 38%-2% (2004) Philippines (SHI: PhilHealth) 76% In-patient, with out-patient for poor 54%+4% (1995) Vietnam (SHI: VSS) 42% Comprehensive 58%-6% (2002) India (SHI: RSBY) 8% In patient, pilot out-patient 61%-2% (2008) Thailand (SHI/tax: UC) 95% Comprehensive 14%-19% (2001) Cambodia (tax/donor: HEFs) 17% In patient, pilot out-patient 40%-22% (2000) Source: own calculations using NHA and Lagomarsino (2012) for enrollment and benefit data. * 2012 or most recent data

Trends in DAH, Asia-Pacific countries, , US$ (millions)

Allocations of ODA by purpose, by country category, 2010 disbursements Health policy, administrative, management HIV, TB, malaria (MDG 6) Other health purposes Reproductive health, family planning Fragile states 23%21%41%14% LICs 13%41%33%12% MICs 21%48%22%9% Island states 54%33%13%0% Asia Pacific region 22%41%27%10% Source: WHO (2012)

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

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.