1. 3 August 2004 Public Health Practice III: FINANCING PUBLIC HEALTH REFORM Thomas E. Novotny MD MPH University of California San Francisco Institute for Global Health

2. Learning objectives  Establish context for health systems  Provide general description of existing healthcare systems  Describe role of World Bank in policy  Present current World Bank policy  Identify issues with proposed direction

3. Populations and disease  Health status indicators  Epidemiologic transition  Demographic transition  Poverty as root cause

4. Declaration of Alma Ata (1978)  Definition of health State of complete physical, mental and social wellbeing Not merely absence of infirmity or disease Fundamentally human right Attainment of highest possible level is worldwide priority and common concern of all countries  Primary care Essential health care Universally accessible Affordable cost

5. Primary health care defined  Addresses main health problems in community  Provides promotive, preventive, curative and rehabilitative services  Broad definition to include proper nutrition, safe water, basic sanitation, prevention and control of communicable diseases, provision of essential drugs  Promotes community self-reliance using local and national resources

6. Elements of Health Systems  Production of resources (people, supplies, facilities, knowledge)  Organization of programs (government, private providers, NGOs)  Economic support mechanisms (source of funds)  Management methods (planning, administration, monitoring and evaluation)  Delivery of services (preventive/curative, primary/secondary/tertiary, public health)

7. Economic Dimensions of Health Systems  Source of payment Voluntary (private insurance, user fees) Compulsory (taxes, social insurance)  How services provided Direct ownership by government Contractual arrangements Private providers paid directly by consumer  How services paid Prospectively – provider assumes risk Retrospectively – costs reimbursed

8. Four key actors  Government  Population to be served  Financing agents  Providers

9. Four key functions  Regulation  Financing  Resource allocation  Providing services

10. Current situation  Government as largest provider universal access high spending on hospitals highly centralized bureaucratic fluctuating budgets poor motivation

11. ISSUES  Market model not panacea  Ability of Ministry of Health to lead transformation  Lack of management capacity to implement changes

12. Current situation  Changing public or private insurance  Half of spending “out-of-pocket” Mainly pharmaceuticals

13. Current situation  Limited power of Ministry of Health  Private provider = quality provider  Lack of access for certain populations

14. World Bank as opinion leader  Health is addressed through economic development  Burden of disease translates into economic terms (DALYs)

15. World Bank as opinion leader  Government and private sector have separate roles prevention/public health essential package of services curative care

16. World Bank as opinion leader  Health system barriers to progress misallocation inequity inefficiency exploding costs

17. Why health sector reform?  Recognition of need for healthy population  Part of overall lending packages  Enhancing the performance of health services

18. Key concepts for health sector reform  Accessibility  Efficiency  Effectiveness  Quality  Consumer satisfaction

19. Accessibility  Equitable  Reduced barriers

20. Effectiveness  Spend money in the right place – most benefit to most people  Improve clinical outcomes  Increase accountability

21. Efficiency  Maximize the money spent  Increase management capacity  Provide incentives

22. Quality  Incentives for change  Information widely available  Accreditation processes

23. Consumer satisfaction  Increased choice  Informed choice  Input to services provided

24. POLICY SOLUTIONS  Enable households to improve health  Improve government investments in health  Promote diversity and competition in financing and delivery

25. POLICY ONE: Enable households  Economic growth policies that benefit poor  Expand investment in schooling  Promote human rights

26. POLICY TWO: Improve government investment  Reduce spending on tertiary and specialty care with low cost benefit  Finance and implement package of public health interventions

27. POLICY TWO: Improve government investment  Finance and ensure delivery of package of essential clinical services  Improve management through decentralization and budget autonomy

28. POLICY THREE: Promote diversity and competition  Government provides public health and essential services  Private insurance for clinical services outside essential package

29. POLICY THREE: Promote diversity and competition  Encourage privatization of all clinical services  Produce information on provider performance

30. Expanding access to health research. www.plosmedicine.org Open-access general medical journal from the Public Library of Science Peer reviewed, international, broad in scope Experienced professional editors, efficient constructive review process, rapid publication Original research and interpretation In PubMed, freely available online, widely distributed in print Submit your best studies and share the results with the world Contact: medicine_editors@plos.org