1. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 1 |1 | + + David B Evans, Director Health Systems Financing Financing for Universal Coverage: Are there Generalizable Lessons from Experience? Are there Generalizable Lessons from Experience?

2. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 2 |2 |OUTLINEOUTLINE 1.Health systems financing and universal coverage: what do we mean? 2.Where are we now and why? 3.Moving towards universal coverage

3. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 3 |3 | Universal Coverage and Financing World Health Assembly Resolution 58.33, 2005: Urged countries to develop health financing systems to:  Ensure all people have access to needed services  Without the risk of financial catastrophe linked to paying for care Defined this as achieving Universal Coverage

4. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 4 |4 | Two components of Coverage 1.Coverage with needed services 2.Coverage with financial risk protection

5. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 5 |5 | World Health Report 2010 Health Systems Financing: the Path to Universal Coverage To be launched on 22 November 2010 Builds on WHO Constitution; Alma Ata and Health for All; WHR2008 on Primary Health Care

6. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 6 |6 |OUTLINEOUTLINE 1.Health systems financing and universal coverage: what do we mean? 2.Where are we now and why? 3.Moving towards universal coverage

7. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 7 |7 | Percentage of births by medically trained persons - DHS

8. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 8 |8 | Overall coverage and level of inequity differ by types of services Generally access to delivery by medically trained person more inequitable than vaccination services Patterns of exclusion: Delivery by a medically trained person (SBA), DTP3 (DTP) and MCV (MCV) – from DHS

9. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 9 |9 | Lack of access, financial catastrophe and impoverishment due to OOPs

10. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 10 | What role does health systems financing play? Three inter-related explanations linked to health system financing 1.Insufficient funds for health in some settings 2.Too much reliance on direct out-of-pocket payments to finance health – limited financial risk protection 3.Inefficiency and inequity in use of resources

11. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 11 | Insufficient Funds Calculations for the high level Task Force on Innovative International Financing for Health Systems: A set of essential services that includes HIV prevention and treatment, and the accompanying health systems development for all interventions – average of $42 per capita (unweighted) in 49 low-income countries in 2009, rising to $65 in 2015 31 of them spent less than $31 per capita per year 2008. Only 8 have any chance of reaching the required funding from domestic sources by 2015

12. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 12 | OUTLINE 1.Health systems financing and universal coverage: what do we mean? 2.Where are we now and why? 3.Moving towards universal coverage

13. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 13 | Solutions 1.Raise sufficient funds (or diversify sources in higher income countries) 2.Reduce reliance on direct OOPs, increase prepayment and pooling to increase financial risk protection 3.Improve efficiency and equity in use

14. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 14 | Selected actions for global community to support countries raise funds  Donor and lending institutions agree to mechanisms to ensure predictable, stable, increased flows for health – and keep promises.  Donors and lending institutions fund priority activities included in PRSPs, SWAPs, or strategic plans - or provide budget support to government. Recipient govts should decide priorities rather than donors

15. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 15 | Actions for Global Community in Supporting Financial Risk Protection  Channel external funds through existing or nascent institutions for pooling funds rather than bypassing them e.g. Rwanda.

16. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 16 | Actions for Global Community in Supporting Improving Efficiency  Reduce fragmentation and transaction costs, particularly in the way external funds are channeled and with application and reporting – Estonia for HIV and drug users; Kyrgyzstan for TB funding. Rwanda permanent secretary reported at WHA2010 that Rwanda has to report on 890 different health indicators to the various donors, almost 600 for HIV and TB alone. Vietnam had 400 aid missions to review health projects in 2009.  Practice what we preach – get more efficient at global level rather than continually introducing more fragmentation, more secretariats – now more than 140 global health initiatives of various types

17. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 17 | Conclusions  Globally still a long way from universal coverage  Solutions are pretty obvious in the big picture – raise enough funds; reduce OOPs and increase prepayment and pooling; improve efficiency and equity  The technical ways to do this are pretty clear as well – is it that the willingness lags behind the technical knowledge

18. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 18 | Spare slide

19. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 19 | Hard Choices

20. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 20 | Heavy reliance on direct payments Countries & Shares of Total Health Expenditure from Out-of- Pocket Payments (2006) Out-of-pocket payments as % of total health expenditure

21. Session 5: From Universal Access to Universal Health Coverage HIV and Health Systems Pre-Conference Meeting, Vienna 21 | Inefficiency: Some countries obtain higher levels of health and coverage for the same expenditure