1. April 2013 1 |1 | Tessa Tan-Torres Edejer Health Systems Financing Priority Setting in Universal health coverage: Choosing services

2. April 2013 2 |2 | World Health Assembly Resolution in 2005 urged countries to develop their health financing systems to:  Ensureall peoplehave access to needed services without the risk of financial hardship linked to paying for care.  Ensure all people have access to needed services without the risk of financial hardship linked to paying for care.  The Resolution defined Universal Coverage ascoverage with: needed health services; financial risk protection; for everyone.  The Resolution defined Universal Coverage as coverage with: needed health services; financial risk protection; for everyone.

3. April 2013 3 |3 | The Three Dimensions (policy choices) Universal Health Coverage

4. April 2013 4 |4 | The Three Dimensions (policy choices) of Universal Coverage WDR93 WHR2010

5. April 2013 5 |5 | How does one choose needed services? What types of services to consider: –preventive, promotive, curative, rehabilitative, palliative –Across the life course –Across different levels of health facilities –procedures and pharmaceuticals and other medical goods – positive or negative lists Main criterion: –Cost-effectiveness to maximize health; Getting the most out of the available funding –Quantifying opportunity costs when choosing less cost effective interventions Implementation issues:

6. April 2013 6 |6 |

7. 7 |7 | Millions miss out on needed health services Percentage of births by medically trained persons

8. April 2013 8 |8 | MDG Tracer Conditions: CEA threshold defined de facto? Antenatal care: 4+ visits Birth attended by skilled health personnel Measles, DTP3, Hib3, HepB3 Children < 5: ARI visit; sleeping under ITN; ORT diarrhoea ART HIV; MCTC HIV + pregnant women TB: case detection rate Additional as possible (based on burden, CEA threshold, budget, logistical feasibility)

9. April 2013 9 |9 | But cost-effectiveness is not that straighforward: Cost-effectiveness might correlate with the other axes. –Many cost-effective interventions are for traditional diseases of the poor –But many cost-ineffective interventions are costly (trauma surgery, cancer drugs, renal replacement therapy) Cost-effectiveness may change: –Because of drop in prices due to national/global volume of sales /international pressure (tiered pricing) –Because of bundling of services (economies of scope); –Start up costs- special problem Even if cost-effective, it may still not be affordable (budget constraints)

10. April 2013 10 | WHO-CHOICE results for an African WHO subregion ________________________________________________________

11. April 2013 11 | Shifting from pure cost-effectiveness to cost effectiveness ++ « Quantitative analysis for qualitative insight » Begin from CHOICE results (cluster of disease or health sector as a whole) Use checklist to identify excluded interventions of equity or priority setting interest Use quantitative techniques to explore concerns & illustrate impact of alternative choices –What resources will be released or foregone? –What existing treatments will have to be displaced? –What health benefits will be foregone? –What is society willing to pay for a more equitable choice of interventions? 11

12. April 2013 12 | Example: Mental health (cluster) At a mental health budget level of $3.50 per capita (India), efficiency results from CHOICE suggest funding the following conditions: –Epilepsy –Alcohol treatment –Depression treatment No funding would be allocated to treatment of bipolar disorder or schizophrenia on efficiency grounds alone However, equity & priority-setting considerations (checklist): –Conditions severe, chronic, lifelong –Not curable, limited capacity to benefit –Bad luck in the health lottery –Interventions are the only means to help 12

13. April 2013 13 | Example: Mental health (cluster) 13

14. April 2013 14 | Example: Trachoma (sectoral) At a budget level of $15 per capita for all interventions (Africa region), efficiency considerations suggest that we can best treat trachoma cases with surgery However, a comprehensive approach to trachoma including surgery & community-based treatment with antibiotics is excluded Equity & priority-setting considerations (checklist): –Preventable –Trachoma blindness is a potentially severe, chronic, lifelong condition –Disease of poverty, poor sanitation, crowding –Concentrated in children (and their mothers) –Comprehensive strategy has positive externalities (reduced spread of infection) In this case, including comprehensive strategy only minimally affects overall efficiency of resource use (e.g. DALYs per $1m expenditure reduce by 3%) 14

15. April 2013 15 | Implementation issues There are already pre-existing services being provided by governments of varying cost-effectiveness; e.g SHI providing coverage for hospitalization with a cap; no description of the disease or intervention being covered (subsidy). Administrative ease The patient does not know on consultation what diseases s/he has or what procedure/medication will be needed

16. April 2013 16 |

17. 17 Health expenditures by condition Sri Lanka 2005

18. April 2013 18 | The World Health Report 2010

19. April 2013 19 | Fig. 2. Health care choices in a low-income and middle-income country. The vertical axis indicates the level of public subsidy, the right-side horizontal axis refers to the population volume classified as poor and non- poor, and the left-side horizontal axis represents clinical health services divided into the minimum and the essential packages. Public subsidies should be close to 100% for the minimum package for the poor. In low-income countries the subsidy should fall, perhaps quite sharply, as resources extend to the non-poor or to interventions outside the minimum package. In middle-income countries the subsidy could extend to the non-poor and can finance part of the essential package only if the minimum package is assured for the poor and all cost-effective services are covered for the entire population (WDR93). LOW-INCOME COUNTRY iNCOME Minimum package Essential package Total population S/DALY Public fiannce share MIDDLE-INCOME COUNTRY Income Minimum package Essential package Total population Poverty line Public fiannce snare S/DALY