1. Exploring the role of insurance-based financing reforms to improve universal coverage of TB services December 11, 2014 Manila, Philippines Alisha Smith-Arthur URC/ USAID TB CARE II Project

2. Outline I.Why examine the role of health insurance in the context of TB service delivery? II.Meeting on TB and insurance based financing reforms, Bangkok, Thailand, Sept 2014 III.Discussion of outcomes, main points, and implications going forward

3. Current context for examining TB in insurance-based systems Continued adoption of the principles of Universal Health Coverage, including emphasis on increasing access to care and reduction of financial burden, with health insurance as a key component Introduction of health insurance programs and push for decentralization leading countries to explore integration of TB services within insurance coverage packages Unclear impact of state-supported health insurance programs on use of TB services and outcomes More information needed to understand the processes and mechanisms to optimize TB service delivery in the context of health insurance introduction

4. Starting point 1: What is the benefit of health insurance (through a TB lens)? Insurance aims to: Protect households from impoverishment due to high out-of pocket spending for TB services. –Requires a system to catch patients early and avoid other spending; needs to minimize costs for more expansive, in-patient curative care Increase access to and use of TB services where payment is normally required at the time of need. Influence provider and consumer behavior to improve quality, efficiency, and effectiveness. Harness private providers to provide TB services within a framework of quality and accountability –Requires high level of oversight, adequate compensation levels, and timely payments.

5. Landscape of health insurance options Types of insuranceFinancing sourceManagement National health insurance General taxesPublic sector Social health insurance Payroll taxes from employers and employees Social security agency, health/sickness fund Community-based health insurance Premium payments from individuals and/or community Community or insurance association Private voluntary health insurance Premium payments from individuals or employers / employees Commercial insurance company Adapted from Health Insurance Handbook, World Bank

6. Starting Point 2. What are the implications of introducing a health insurance program (through a TB lens)? Defining the degree of integration of TB services Establishing roles and responsibilities of NTP and insurance authority Developing coordination mechanisms for decisions around policy, coverage, oversight, targets Affect of insurance programs on TB objectives: outcomes, case finding, reduced financial burden (i.e., social support and patient-centered care)

7. I.Policy: TB and UHC policy objectives Defining landscape of insurance programs and relationship to TB Incorporating strategic TB objectives within UHC reforms II.Administration and organization Outlining coordinated responsibilities for insurance and TB authorities Defining mechanisms for routine engagement and coordination III.Service deliveryDefining a benefits package for TB services Ensuring all patient needs are covered IV.Facilitating access and utilization Continuum of care between service providers (referrals and follow up) Informing and educating TB patients around access to services, required costs V.Engaging more care providers Accreditation and role of other professional associations Reimbursement and incentivizes VI.Ensuring quality of careMonitoring patient outcomes Promoting patient-centered care

8. Current approach to health insurance in WPR representative countries Among representative countries: 3 with existing or planned national health insurance programs Health insurance funding used for clinical services, diagnostics, enablers (wide variation between program models) Universal perception among respondents that introduction of health insurance will positively impact TB case notification and quality of care, and decrease patient OOP expenditures

9. Universal Health Coverage Coverage: Population coverage includes high risk TB populations TB services included in coverage package (including MDR TB, EPTB) Benefits package promotes community level services Access and Use: Distribution of services sites targeted to reach high risk TB populations Supports active case finding Transport and social support addressed Linked awareness and messaging with TB awareness efforts Quality of Services: In-service providers comply with TB service delivery standards Sufficient infrastructure/supplies for TB diagnosis and drugs Providers have capacity to provide TB diagnosis and treatment Linked to community- based care Improved TB Outcomes Framework for Evaluating TB Services within UHC

10. Meeting on TB and insurance-based UHC financing “Exploring the promise of improving access and delivery of TB services through insurance-based financing reforms,” Bangkok, Thailand, Sept 2014 Participation from 9 countries in WPR and SEAR Participation from NTP, Finance, Insurance authorities, others  Diverse models, experiences and goals for UHC financing

11. Meeting Objective and Purpose Provide a forum for information sharing and review of current systems for ensuring access to, and provision of, essential TB services and core public health functions in the context of UHC financing reforms in Asian countries Discuss and develop common principles, best practices, and policy options around essential public health functions and core services for TB control and care in insurance-based systems Create a foundation for further investigation and development on framework guidance

12. Topic areas for presentation and discussion TB and Universal Health Coverage Overview of regional models of insurance-based financing and TB service delivery Defining a benefits package for TB services Planning and administering TB services effectively in an insurance-based system Engaging more providers effectively through insurance-based financing

13. I. Programmatic and policy roles The role and functions of the NTP in an insurance- based financing system and the impact of decentralization: Necessity of defining the essential public health functions of a national TB program –Policy and supervision functions –Oversight and support for supply and TB commodity management –Division of responsibilities for TB and MDR TB diagnostic and clinical services

14. I. Programmatic and policy roles Coordination vs. fragmentation: Importance of step-based, coordinated planning for phased introduction of health insurance between Finance, insurance authority and NTP –Avoid disruptions in free access to services –Rational decentralization –Two-tiered delivery networks (NTP and insurance based providers)

15. II. Provider engagement, payment, and quality of care Effectiveness of payment mechanisms and provider engagement function: Address the complexity in the development of effective purchasing and reimbursement mechanisms for TB providers –Potential models (i.e., case-based payments, capitation, fee- for-service) with relative (dis)advantages depending on the type of service, service site, and administrative requirements –Strong oversight functions needed –Development of additional organizational layers

16. II. Provider engagement, payment, and quality of care Provider follow up, monitoring and quality of care: Mechanisms for ensuring in-network providers deliver services according to TB standards –Effectively matching payments to incentives or incorporate targets for service delivery outcomes or outputs –Linked payment mechanisms to structured accreditation and certification systems Facilitates oversight by NTP and/ or insurance authority for compliance to standards and quality of care Requires robust organizational management, in the context of decentralization

17. III. Patient needs and patient-centered care Impact on reducing patient costs: More evidence needed to demonstrate impact on reducing OOP costs for TB patients. Common challenges: –Access to an accredited provider vs. shopping around –Utilization of insurance benefits –Gaps in coverage for needed clinical services –Lack of coverage for social support benefits

18. Conclusion Stronger engagement and continued consultations between National TB Programs and other planning authorities around UHC financing and the role of health insurance Develop further evidence on the impact of the impact of health insurance on the TB outcomes and economic wellbeing of beneficiaries Introduce guidance on development of financing and/or insurance-based reforms in the context of national TB and UHC objectives

19. Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get worse. To the hopeful it is encouraging because things may get better. To the confident it is inspiring because the challenge exists to make things better. -King Whitney Jr.

20. Thank you!