presentations during a national universal health coverage...

Presentations during a National Universal Health Coverage

Advocacy Symposium

Taj Pamodzi Hotel Lusaka, Zambia30th June and 1st July 2015

Table of Content

1. Overview of UHC in ECSA Region-ECSA Secretariat

2. UHC as a Policy Issue in Zambia Now and Beyond-MOH Zambia

3. Government Financial Allocation-MOF Zambia

4. Health Financing Strategy and Social Health Insurance in Zambia-MOH

5. Research and existing evidence-University of Zambia

6. Defining Zambia’s Proposed SHI Package-NHI coordination unit

East Central and Southern Africa Health Community

Advocacy symposium on Universal Health Coverage

Overview of UHC in ECSA Region

Taj Pamodzi Hotel, Lusaka Zambia

30th June- 1st July 2015

Dr Walter Denis Odoch

Manager, Health Systems and Services Development Program, ECSA

Presentation Outline

- Overview of East, Central and Southern Africa Health Community (ECSA-HC) structure

- Objectives of the advocacy symposium on UHC- UHC in ECSA Member states

4


5

- Inter-governmental regional health organization established in 1974 under the auspices of the Commonwealth Secretariat, London to foster and promote regional cooperation in health among Member States

- Commonwealth Regional Health Community for East, Central and Southern Africa (CRHC ECSA)

- From 1980, it has functioned under the direct control of Member State governments

- In Nov 2002 Health Ministers Conference adopted the name ECSA-HC- Active member states: Kenya, Lesotho, Malawi, Mauritius, Swaziland, Tanzania,

Uganda, Zambia and Zimbabwe.

East, Central and Southern Africa Health Community

ECSA-Health Community structure

Expert Committees Directors Joint Consultative Committee (

ECSA Secretariat

Advisory Committee

Conference of Health Ministers

Symposium Objectives

To contribute to existing global and regional efforts on UHC and energize the local discourse with a view of increasing resources and its efficient use in the health sector though establishing and/or facilitating country level advocacy efforts for UHC.

- Creating awareness among key stakeholders about UHC

- Act as an advocacy event for the UHC in the member state

7


Socioeconomic development and health; Need for UHC

- Good health is essential to sustained economic and social development

and poverty reduction.

- Access to needed health services is crucial for maintaining and

improving health.

8


Socioeconomic development and health; Need for UHC

- Governments and development partners are engaging in political and

technical discussions on how to expand health coverage.

- Need for Reforms:- legal, financial, and political considerations to

determine the best approaches.

- Details vary from country to country, common goals• cost burden of health care is shared widely and equitably,

• patients and their families have increased coverage,

• resources are better utilized, and health outcomes are improved.

9


Commitments to increasing Health Coverage- World Health Assembly (WHA) 2005

resolution, WHA 58.33

- WHA Resolution on primary health care (WHA 62.12),

- WHA Resolution on Social Determinants of Health (WHA 62.14)

- The Pan African Congress on UHC

- UNGASS resolution on affordable universal healthcare.

10


- 2010: HMC52/R2:Universal Health Coverage

- 2010: HMC50/R1: Health Insurance and Financing

- 2008: HMC46/R1: Strengthening Health Systems to Ensure Equitable Access to Health Care

- 2003:HMC/42/R5.1 and R6: Resource Mobilization and Alternative health financing

Tracking commitments on increasing Health Coverage

- Need for clear Goals:

- shape political agendas and influence resource transfers

- The way goals and indicators are defined influences how the world understands

development

- Health is central to development: it is a precondition for, as well as an

indicator and an outcome of progress in sustainable development

11


Universal Health Coverage (Proposed SDS goal 3)

GOAL 3: Ensure healthy lives and promote wellbeing for all at all ages

All countries achieve universal health coverage at every stage of life, with

particular emphasis on primary health services, including mental and

reproductive health, to ensure that all people receive quality health

services without suffering financial hardship. ………

12


Universal Health Coverage; Three things;-

- All people having access to health services that they need

- Health services being of sufficiently good quality

- People access health services without the consequence of financial

hardship

13


How do you judge progress

14


Strategies towards UHC

- Raise sufficient funding for health:- Mobilize more resources both locally and internationally

- Reduce the reliance on direct payments to finance services:- Remove financial risks and barriers to access through prepayment and pooling mechanisms

- Promote solidarity of the whole population whereby the rich subsidize the poor, and the healthy subsidize the sick

- Improve efficiency and equity:- Promote efficient use of available resources and eliminate waste

- Increase the quality of health services

15


ECSA Member States; how are we doing in financial protection

16

Per capita total expenditure on health at average exchange rate (US$)

0

50

100

150

200

250

300

350

400

450

500

Tanzania Zambia Kenya Lesotho Malawi Mauritius Swaziland

US

D p

er

pe

rso

n p

er

ye

ar

2006 2008 2010 2012 2013


17

20.0

25.0

30.0

35.0

40.0

45.0

50.0

55.0

60.0

65.0

70.0

2005 2006 2007 2008 2009 2010 2011 2012 2013

Perc

en

t

Years

United Republic ofTanzania

Zambia

Kenya

Lesotho

Malawi

Mauritius

Swaziland

Private Health Expenditure as % of Total Health Expenditure


18

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2005 2006 2007 2008 2009 2010 2011 2012 2013

Perc

en

tOut of Pocket expenditure as a Percentage of Total Private Health Expenditure

Tanzania

Zambia

Kenya

Lesotho

Malawi

Mauritius

Swaziland

ECSA Member States; how are we doing in service coverage

19

0

10

20

30

40

50

60

70

80

90

100

Kenya Lesotho Malawi Mauritius Swaziland Tanzania Zambia Zimbabwe

Pe

rce

nt

Percentage of birth attended by a skilled health personnel

2005 2007 2010 2014

ECSA Member States; how are we doing in terms of Impact

20

0

200

400

600

800

1000

1200

2000 2005 2008 2010 2012

Ma

tern

al D

ea

th p

er

10

0,0

00

liv

e b

irth

Year

Kenya Lesotho Malawi Mauritius Swaziland

Tanzania Uganda Zambia Zimbabwe

Maternal Mortality

ECSA Member States; how are we doing in terms of Impact

21

0

20

40

60

80

100

120

140

160

180

Kenya Lesotho Malawi Mauritius Seychelles Swaziland Tanzania Uganda Zambia Zimbabwe

Un

de

r 5

de

ath

pe

r 1

,00

0 l

ive

bir

th

2000 2005 2009 2012

Under five mortality rate

ECSA Secretariat Efforts

- Supporting regional monitoring and sharing of progress and best

practices on UHC in ECSA Health Community

- Catalyzing advocacy initiatives for UHC in the region

- Technical support in health financing reforms

22


Conclusion

- In addition to the MDGs there are “new” issues (non-communicable

diseases, health systems, determinants of health and health security)

- UHC characterizes health in a broad sense, in a way that is measurable

and supports generation of political traction and public understanding.

- Universal Health Coverage is a dynamic process. It is not about a fixed

minimum package, it is about making progress on several fronts

23


THANK YOU FOR YOUR ATTENTION

UHC as a Policy Issue in Zambia Now and Beyond

Ministry of Health Zambia

UHC AS A POLICY ISSUE IN ZAMBIA NOW AND BEYOND

26

30th June, 2015

SYMPOSIUM ON UNIVERSAL HEALTH COVERAGE

27

• Population – 15.02 million

• GNI 2012 US$ 1,550 per capita,

• Gini 0.62

• Health status

Life expectancy at birth- 50yrs M: 53 F

U5MR 75/1000 Live Births,

MMR 398/100,000 Live Births

Skilled Deliveries- 63%

• Fiscal space: Tax revenue 23% of GDP ,

• Gov’t health spending 9.9 % total budget (2015)

• Total Health Expenditure (THE)

US$ 112 per capita, 6.4% GDP

Source: Public 50%, External Resources 39%,

OOP 7%

Zambia: Country Profile

DEFINITION OF UNIVERSAL HEALTH CARE (UHC)

"Financing systems need to be specifically designed to:

Provide all people with access to needed health services (including prevention,

promotion, treatment and rehabilitation) of sufficient quality to be effective;

Ensure that the use of these services does not expose the user to financial

hardship"– World Health Report 2010, p.6

DEFINITION EMBODIES SPECIFIC AIMS (UNIVERSAL COVERAGE

OBJECTIVES)

Equity in service use;

Quality; and

Financial protection…

…for all

Promotes cross-subsidies in overall health system:

Everyone should benefit according to need for care

Everyone should contribute according to ability to pay

THREE DIMENSIONS OF UHC

1.

2.3.

TWO IMPORTANT COMPONENTS OF THE ZAMBIAN

FRAMEWORK OF HEALTH DELIVERY

1. A systems Approach

2. Universal Health Coverage Principles

Note: These are not exactly as espoused internationally but are

deliberately adapted to the local Zambian situation. The next

slides explain this

OBJECTIVES TO BE ACHIEVED

To address the issue of “under funded” health sector and barriers to accessing health

services, the GRZ is proposing to set-up and implement a National Social Health

Protection Scheme.

The National SHP scheme will enable all citizens of Zambia to access a comprehensive

package of quality health services on a timely manner and without financial hardship.

Zambia’s Policy Emphasis on the Wider Health Financing Agenda for UHC

Coverage of Financing for health: The Financing for Health program should not be for

the privileged, select few or the elite but for all i.e. the “Zambia National Health Service”;

Cash Flow: The design of the health financing strategy, including the SHI program must

be designed to withstand cash flow fluctuations in the sector so that there is no

interruptions in the flow of essential services to the people;

Drug Supply: The essential drug list must be appropriately designed to capture the

necessary drugs and this essential drug list must always be available;

Result Based Financing: The health financing must have an incentive based

financing/Result Based Financing mechanism;

The Poor and Vulnerable: The welfare of the poor and vulnerable as well as special

population groups such as the elderly and differently abled must be well secured in the

program.

Source: Dr. J. Kasonde, Hon Minister of Health, MP, April 2014

THE MAIN NHSP TARGETS FOR ZAMBIA

Reduce the under-five mortality rate from the current 119 deaths per 1000 live births to 63 deaths per 1000

live births by 2015;

Reduce the maternal mortality ratio from the current 591 deaths per 100,000 live births to 159 deaths per

100,000 live births by 2015;

Increase the proportion of rural households living within 5km of the nearest health facility from 54.0 percent

in 2004 to 70.0 percent by 2015;

Reduce the population/Doctor ratio from the current 17,589 to 10,000 by 2015;

Reduce the population/Nurse ratio from the current 1,864 to 700 by 2015;

Reduce the incidence of malaria from 252 cases per 1,000 in 2008 to 75 in 2015;

Increase the percentage of deliveries assisted by skilled health personnel from 45 percent in 2008 to 65

percent by 2015; and

Reduce the prevalence of non-communicable diseases associated with identifiable behaviours.

What is the social health protection

model being proposed in Zambia?

STRATEGIC FRAMEWORK

Phased approach in population coverage starting with the formal sector and vulnerable groups of population

and gradually extending coverage to all citizens of Zambia

Seek synergies with existing institutions and systems in a cost-efficiency approach

Coordination with other Social security programmes for contribution collection, identification of the poor and control

of compliance

Linkage with SCT scheme to cover the Vulnerable groups

Coordination with other Social security branches such as Pension or Maternity now being developed

Linkage with reformed pension scheme to collect contributions from the formal sector workers

Linkage with health system strengthening programmes and Health Professions council to improve and guarantee the

quality of services provided to ensured members

ZAMBIAN MODEL OF SOCIAL HEALTH PROTECTION SCHEME

Phase 1:

To cover 200,000 vulnerable households under the social cash transfer scheme (1,000,000 vulnerable people covered at inception) covered from inception

To cover 650,000 employees in the formal sector (private and public sector) through the existing systems (3.3 million people)

Implication is that 4.3 million Zambians i.e. 30% of population covered at inception

Phase 2:

Informal sector to be rolled in the second phase

This is a significant and important group (only 11% of workforce is in formal while the rest are in the informal)

1. The proposed Zambian social health insurance model is single pool, pro-poor program that ensures cross

subsidization amongst different population groups and protects beneficiaries from catastrophic expenses

2. It fits well in the social protection framework as it is part of the policies and programs designed to reduce

poverty and vulnerability by diminishing people's exposure to risks, and enhancing their capacity to manage

economic and social risks associated with sickness

The Zambian health sector is anchored on the WHO health systems framework

Health Resources for Health

Service Delivery

Health Care Financing

Infrastructure, Equipment &

Commodities

Health Management

Information System

Leadership and Governance

Improved Efficiency

Financial Risk Protection

Responsiveness

Improved Health (Level &

Equity)

Access Coverage

Quality Safety

System Building Blocks of the

Zambian Health System Outcomes/Goals

UHC IN THE ZAMBIAN CONTEXT…INITIATIVES

How to best balance

cost, quality, and access

in a manner that is both sustainable and

consistent

with social values and political goals?

• Removed User Fees at PHC level• Increased Govt. allocation to Health by

300% in last 5 years• Improved efficiency through resource

tracking & revised RAF• Improve supply chain mgt.

• Construction of 650 Health Posts

• Upgrade & Modernization of

Hospitals

• 160 Basic Life Support Ambulances,

5 Mini & 42 Advanced Life Support

• 9 Mobile Units

• Modernization of facilities to diagnose

and treat patients

• Training of more Health Workers (new

Medical school & TIs)

• Salaried CHW

• Improve supply chain mgt.

Delivering high quality Providing access

Responding to costs

UHC IN THE ZAMBIAN CONTEXT… OTHER INITIATIVES

Introduction of SHI

Draft SHI bill in place

Sensitization meetings on SHI with key stakeholders

Zambia Household Health Expenditure and Utilization Survey

Informal Sector Rapid Assessment

Mid Term Review of the National Health Strategic Plan

ZDHS surveys

SOCIAL HEALTH PROTECTION IN ZAMBIA AND UHC

(Equity, Quality & Protection From Financial Risk)

Health Financing Strategy

The health financing strategy Government is working on is designed to provide all people with access to

needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to

be effective; ensuring that the use of these services does not expose the user to financial hardship (SHI is

not a silver bullet for UHC but a component of a wider HCS)

Breath of Coverage

Inclusion of the informal sector, the poor & indigent is critical for Universal Health Coverage

Type of Service

It is not just about reaching everyone, services must be meaningful

Services must be holistic - from prevention, promotion to urgent medicals services.

CHALLENGES IN IMPLEMENTATION

Meeting expectations of the insured population in availability and quality of health services

Covering the informal population – registration and contribution collection

Developing mechanisms to cover near-poor and those not covered by SCT

Developing capacities and retaining human resources

Mobilizing financial resources for subsidies to the Vulnerable groups

Developing awareness on social health protection from insured population and employers

Reaching administration efficiency in a public institution

Current Landscape of Government Financing and Health Financing Options

Government Financial Allocation Ministry of Finance Zambia

GOVERNMENT RESOURCE

ALLOCATION

Ministry of Finance

OUTLINE OF PRESENTATION:

Determining the Resource Envelope

Sources of Government Revenue

Developing Broad Expenditure Allocations

Determining Intersectoral Allocations

Issues that Determine Resource Allocations; and

Prioritising of resources within MPSAs

Determining the Resource Envelope

First step in MTEF process requires maintenance of a consistent

Macroeconomic Framework (3 year period)

Macroeconomic Frameworks depicts:

changes of the economy as a whole

changes in the Monetary sector and provides the extent to which Government can

borrow from the system

external flows, including debt payments donor grants, exports and imports

the level of resources that are available for spending by the public sector

Determining Resources contd…..

changes in the Real sector i.e Output and prices

changes in the Fiscal Sector, including how much Government projects

collect in terms of revenues and how much government is projecting to

spend.

The Fiscal Framework indicates/projects the total resources that are

available for the Central Government Operations ( Expenditure) in the

3 year period


Sources of the Revenue include the following:

Domestic Revenue

Tax and non-tax

Miscellaneous Revenues

Exceptional revenue etc

Foreign Grants

Grants (project & programme)

Financing

Domestic Borrowing

External ( Programme & Project loans)



Once the total resources are estimated, including donor inflows, the next stage is to provide for:

Constitutional Expenditures, i.e. those expenditures for which government has a legal obligation. These include debt payments, pensions, transfers to local government, earmarked revenues for special funds.

Contractual commitments for the payment of personnel ( including pension entitlements that are due or will fall due)

Domestic Arrears (Debt servicing and amortization) and, in some cases, contracts for the delivery of goods and services that extend between budget periods

Agreements and accords with bilateral and multilateral agencies for the counterpart financing for projects and programs


Cont’d….

There are some broad expenditure policies that influence the allocation of

resources, including:

appropriate levels of staffing and structure of the civil service

wage policies and any planned salary increases

balance between personnel cost, recurrent costs and capital expenditures

policies on levels of donor flows, i.e. the degree of aid dependency

Fiscal Framework

Once the Resources Envelope and the Broad Expenditure categories

are established, the next step is to develop the Fiscal Framework.

The Fiscal Framework indicates the total resources that are available

for the Central Government Operations ( Expenditure) in the 3 year

period

Determining Inter-Sectoral Allocations

The basis for and processes of decisions on resource allocation between sectors and MPSAs’ is based on a combination of

Top down information on government priorities and policies

Bottom up requirements from each MPSA of the funds required to achieve the agreed government objectives and targets

Determining Inter-Sectoral Allocations

Macroeconomic Framework

Resource Envelope

Administration Economic and

Infrastructure

Social Sector Public Safety Sector

Constitutional Expenditures

Debt Payments, Pensions etc

Government Policies and Priorities

MPSA Policies and Priorities

Expenditure Requirements of priority

Services and Infrastructure

MPSA Ceilings

Government policy informs

MPSA policies

Scope of MPSA services and

infrastrucrure influenced by

policies

Costs of policies influences

priorities and allocation of

resources

Top DownBottom Up

Options presented to Cabinet on

a) Allocating additional resources, or

b) redefining policies and programmes to fit

within resources available

Issues that Determine the

Allocation of ResourcesThe decisions about resources allocation between and among

MPSAs’ needs to be based on a combination of the

following factors: Allocation of funds to achieve set Government objectives

An analysis of the issues within a sector and the constraints to achieving planned outcomes needs to guide resource allocations.

Clearly defined Sectoral linkages, such as the need for roads in the agriculture and tourism sector, so as to define the requirements for roads expenditures.

The role of government in the sector, i.e. whether government is:

a provider of services and infrastructure,

a facilitator of private sector development ,

a regulator of private sector activity; so as to determine the levels of resources required in a sector.

Issues that Determine the

Allocation of Resources

Facilitator vs provider:

For example; although agriculture and tourism are priority sectors for government, government’s role is mainly to facilitate and regulate private sector development. Therefore the resource requirements are not as high as if government were providing services in these sectors.

In the social sector of health, were the Government is the provider, the resource requirements are high.

Importance of prioritizing within MPSAs

MPSAs also need to prioritise within their own organisation to make use of limited resources

The factors that would guide the allocation of resources within an MPSA are the same as those at the national level, i.e. Those programmes that achieve government objectives with the least cost and within the resources

(both financial and human) available to the organisation

Based on the role of government for the particular programme, i.e if government is the main provider of a service then the expenditure requirements would be higher than if the government is mainly facilitating private sector growth

Whether there are options for involving the private sector and/or NGOs and communities in the delivery of services, as well as other options such as charging for services

2014-2015 Allocations to the Health Sector

2014 Allocations:

FUNCTION K’million Percentage of

Budget

Health 4,228.4 9.9

Drugs and Medical Supplies 738.7

Medical Infrastructure and Equipment 312.3

TOTAL BUDGET 42,682.0

2014-2015 Allocations to the Health Sector

2015 Allocations:

FUNCTION K’million Percentage of

Budget

Health 4,464.09 9.6

Drugs and Medical Supplies 753.52

Medical Infrastructure and Equipment 268.24

TOTAL BUDGET 46,666.56

Current Landscape of Government Financing and Health Financing Options

Health Financing Strategy and Social Health Insurance in Zambia

Ministry of Health Zambia

Advocacy Symposium for Scaling up Universal Health Coverage in

ECSA-Health Community

Health Financing and Universal Health Coverage in Zambia

Presented by

Mubita LuwabelwaDeputy Director (Planning & Budgeting) - MOH

Pamodzi Hotel, Lusaka - Zambia, 30 June – 1st July 2015

Some Key Policy Level Questions in the UHC Agenda

1. Where shall we be in tomorrow’s world?

2. What key lessons can today’s UHC agenda learn from history?

3. Is the “Trinitarian” representation of UHC achievable?

4. Should the “Health Sector Proper” crowd out other sectors (SDH) in financing the UHC agenda?

Some Global HighlightsKey variables for the UHC Community to reflect on

• Sub-Saharan Growth to remain at 5% per annum in 2013 (IMF, 2013)

• 6 of the fastest growing economies in the world in the past decade are in Sub-SaharanAfrica, (The Economist, May 2013)

• 1 billion people do not have access to health care; 100 million fall into poverty everyyear due to illness

• Sub-Saharan Africa is now the second fastest-growing region in the world, trailing onlyemerging Asia (IMF, 2013)

• Translating real GDP growth to quality of life & poverty reduction remains a challenge inZambia and the Sub region

• By 2050, almost one quarter (23%) of the working age population will be in Africa

• Four out of 10 most populated countries are in Africa, and the fertility rate in Africa iscomparably very high

• Sub-Saharan Africa has 11% of world population, 25% of the world burden of diseasebut only 3% of world’s HRH (WHO)

• 56.0 million people die everyday year (6,390 deaths per hour. 153,000 deaths per day4,590,000 per month)

• 146.0 million babies are born every year, (16,600 per hour, 400,000 every day, 12million every month

• Net increase of 250000 human beings a day, 90 million per year (1.4%) - We arecrowding 6,500 million people on the planet.

• Income distribution remains high (gini coefficient = 0.40 – over 0.52)

There is no shortage of growth in Africa(The Economist, May 2013)

Health Financing at a Global Level

Good NewsRegional Governments are increasingly spending more on health

(e.g. Malawi and Zambia)

Sadly, less money is still spent on each individual in the region

Bad NewsThe UHC Agenda in the ECSA region is still threatened by the dependency syndrome

There is some progress in financial protection in the region – more remains to be done

Zambia: Growth in Health Sector Budget 2010-2015

Source: Ministry of Health

Financing Sources

• The main financing sources are Government, CPs & Households

• Employers and other sources continue to play a minor role in health financing

On average•Government – 50%•Donors – 39% (mostly vertical programmes & off-budget)

•Households (OOPs) - 7%•Employers – 4% •NGOs - <1%

NoteOver 90% of operational funds are now by Government

General Revenue (Tax) is Main Source of funding with relatively low OOPs (preliminary)

Zambia: Total Health Expenditure by Function (preliminary)

• Curative - 54%

• Prevention or Public health programs -27%

• Health Administration & Insurance – <6%

• Health Care Related – 6%

• Other – 6%

Note

Rising administration costs need to be contained

.

0%

10%

20%

30%

40%

50%

60%

Series1

Zambia: Overall Health Expenditure

Note:• Overall increase in

expenditure on health

• Increased Government spending

• Declining overall expenditure by CPs (relative)

• However, CPs remain key funders of key vertical programmes such as Malaria, HIV/AIDS etc

Expenditure by Source

50%

4%7%

0%

39%Central Government

Employer funds

Households

NGOs

Rest of the World

Social Determinants of Health and UHC

Is Increased financing of the health sector alone at the expense of other

sectors enough to reach UHC?

Collaboration between Ministries responsible for Health and other

sectors is critical if UHH is to be achieved

Key Role of Social Determinants of Health

Category Determinant Details Sphere

Cultural Status of woman Elements of patriarchy ‘Cultural

Propriety’

informal

Social Age and sex

Socioeconomic Household resources Educational level

Maternal occupation

Marital status

Economic status

Economic Costs of care Treatment

Travel Time

Physical

infrastructure

Type and severity of illness

Geographical Distance and physical access

SDH: Factors Influencing Health Services.

ENVIROMENTAL POPULATION CHARECTERISTICS HEALTH OUTCOMES

BEHAVIOR

Health Care

System

External

Environment

Predisposing Enabling Need

Characteristics Resources .

Personal

Health

Practices

Use of

Health

Services

Perceived

Health Status

Evaluated

Health Status

Consumer

Satisfaction

Source: Anderson, RM (1995): Revisiting the behavioral model and access to medical care: does

it matter? Journal of Health and Social Behavior, 36:1-10

Where are we on the match towards UHC as a region?

• There is need to have a proper analysis on the dimensions of coverage that reflect a set of

policy choices about benefits in reforming health financing systems towards universal coverage

in the ECSA region

1) Population: Who is covered in ECSA-HC?• The large informal sector in the region threatens coverage of population -through pre-payment schemes

• Free primary health care is also not sufficient

• Access remains a challenge for more people due to costs, distance etc.

• The private sector still largely remains to be tapped to fill the gap

1) Services: Which Services are Covered in ECSA-HC?• Low HRH still threatens quality of care (3% of Global HRH and yet 25% of Global disease burden - Africa)

• Access to tertiary level care remains a big challenge

• Technology such as telemedicine is an opportunity

• Treatment abroad is very expensive and inequitable

1) Direct Costs: Proportion of the costs Covered in ECSA-HC?• Population covered by prepayment system remain low

• Transport due to distance travelled & food for the patient and care giver remain the highest costs (ZHHEUS and KHHEUS)

• Charges for diagnosis still exorbitant and a hindrance for better health

Key UHC Considerations - Past and Present

There is no need to re-invent the wheel for UHC for ECSA-HC member states

Free lessons are abundant to learn from

Modern day achievements from countries such as Thailand, including regional pioneers such as Tanzania, Ghana

However, there is need to contextualize the design of UHC programs to country and regional levels if UHC is to be achieved

Is there need to re-invent the Wheel for UHC for ECSA – Free Lessons are there

The Beveridge Model (National Health Model)

Named after William Beveridge, the daring social reformer who designed Britain’s NHS.

Features• Health care is provided and

financed by the government through tax payments

• Most hospitals and clinics are owned by the government;

• Some doctors are government employees, but there are also private doctors who collect their fees from the govt.

• These systems tend to have low costs per capita

• Examples: Britain, Spain, Scandinavia New Zealand. Hong Kong still; Cuba

The Bismarck Model (Social Insurance Model)Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Features• It uses an insurance system

where a fund is usually financed jointly by employers and employees through payroll deduction.

• It covers everybody, and is not for profit.

• Doctors and hospitals tend to be private in Bismarck countries

• Tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.

• Examples: Germany, France, Belgium, the Netherlands, Japan, Switzerland, In Latin America

National Health Insurance Model

System has elements of both Beveridge and Bismarck.

Features

• Uses private-sector providers,but payment comes from agovernment-run insuranceprogram that every citizenpays into.

• No financial motive to denyclaims and no profit

• It’s a universal insurancescheme & tends to be cheaperand much simpleradministratively

• National Health Insuranceplans also control costs bylimiting the medical servicesthey will pay for, or by makingpatients wait to be treated.

• Examples: Canada, Taiwan,South KoreaNote

1. The two main models are the Beveridge and Bismarck Models. The NHIM is a combination of the two

2. There are other models such as the private insurance model, out of pocket model but these are generally variants of the 2 main models and this includes the NHI model above.

What has Zambia Learned from the 3 Dimensions of UHC

• Choices need to be made about proceeding along each of the three dimensions, in many combinations, in a way that best fits Zambia’s objectives as well as the financial, organizational and political context in Zambia.

• Extending the coverage from pooled funds along the three dimensions calls for health financing reforms and actions leading to:

1) An increase of available funds for health2) An increase in the share of these funds collected through prepayment and the arrangements for pooling them3) Efficiency gains4) Upholding and increasing the quality of health services.

Source: Adapted by MOH from WHO Principles

Why SHI Scheme when there is “Free” primary health care?

Despite the free primary health care policy, Zambian households still have topay for their health expenses:

• At secondary and tertiary levels• At primary level: for drugs, diagnostic tests and others services that may

not be available at the government facilities• In the private sector

“Free” health care for the citizens are limited to what the Government canafford.

Costs incurring at the point of service are the major financial barrier for theZambian citizens to access the right care at the right moment.

SHI Program is not a silver bullet for UHC in Zambia but sits well in the widerhealth financing reform agenda

Zambia is in the Process of Implementing a SHI Scheme in Zambia BUT……..

Zambia’s Policy Emphasis on the Wider Health Financing Agenda for UHC

Coverage of Financing for health: The Financing for Health program should not be for

the privileged, select few or the elite but for all i.e. the “Zambia National Health Service”;

Cash Flow: The design of the health financing strategy, including the SHI program must

be designed to withstand cash flow fluctuations in the sector so that there is no

interruptions in the flow of essential services to the people;

Drug Supply: The essential drug list must be appropriately designed to capture the

necessary drugs and this essential drug list must always be available;

Result Based Financing: The health financing must have an incentive based

financing/Result Based Financing mechanism;

The Poor and Vulnerable: The welfare of the poor and vulnerable as well as special

population groups such as the elderly and differently abled must be well secured in the

program.

Source: Dr. J. Kasonde, Hon Minister of Health, MP, April 2014

Zambian Model: National Social Health Insurance Scheme

Phase 1:

• To cover 200,000 vulnerable households under the social cash transfer scheme (1,000,000 vulnerable people covered from inception)

• To cover 650,000 employees in the formal sector (private and public sector) through the existing systems (3.3 million people) Implication is that 4.3 million Zambians i.e. 30% of population covered at inception

Phase 2:

• Informal sector to be rolled in the second phase

• This is a significant and important group (only 11% of workforce is in formal while the rest are in the informal)

1. The proposed Zambian social health insurance model is single pool, pro-poor program thatensures cross subsidization amongst different population groups and protects beneficiariesfrom catastrophic expenses

2. It fits well in the social protection framework as it is part of the policies and programsdesigned to reduce poverty and vulnerability by diminishing people's exposure to risks, andenhancing their capacity to manage economic and social risks associated with sickness

3. SHI is aimed at ensuring that:• All Zambians, are covered in a phased approached, and irrespective of their socioeconomic status

have access to quality health care• Quality health services are delivered equitably• The covered population does not pay for accessing health services at point of use• The covered population has financial risk protection against catastrophic health expenditure

What Progress has been made so far

• Legal framework: SHI included in key policy documents, SHI Bill ready, consultations process with key stakeholders on-going

• Organizational design set-up

• Major components of the scheme designed

• Discussion with MoLSS, MoJ, Cabinet Office & other stakeholders to ensure alignment with Pension reform on-going

• On going design of collection contribution mechanisms

• Capacity building on Social Protection and Social Health Insurance started

• Informal Sector Rapid Assessment (April 2014)

• Updated Actuarial Assessment (2013)

• Zambia Health Expenditure and Utilization Survey (Report Due in July 2014)

• Zambia Demographic Health Survey (Report Ready)

Other Key Issues in preparation for the UHC Agenda

Health Financing Strategy

A wider Health Financing Strategy is being

worked on

SHI is an important but not exclusive feature of

the strategy

Infrastructure development and Medical

Equipment

Construction of 650 Health Posts

Construction of 30 District Hospitals with an

additional 8 to be added this year

Upgrade and Modernisation of Hospitals

Building Flagship Hospitals

160 Basic Life Support Ambulances,

5 Mini & 42 Advanced Life Support

9 Mobile Units

Legislative Reforms

SHI Bill

NHS Act

Hospital Reimbursement Reform

National Health Facility Standards (HPCZ)

PHC Reengineering

Improving Supply Chain Management

E-Health Strategy

Improving Hospital and District Management and Governance

Review Health Package, Standard and EML

Establishment of Health Research Authority

Health Care financing strategy

Population registration (with Home Affairs)

Human Resources Management

New Medical Schools

National Training Institution

Salaried Community Health Assistants

National Training Operational Plan

HRH Strategy for Health

Challenges Foreseen in Implementation

• Meeting expectations of the insured population in availability and quality of health services

• Covering the informal population – registration and contribution collection

• Developing mechanisms to cover near-poor and those not covered by SCT

• Developing capacities and retaining human resources

• Mobilizing financial resources for subsidies to the Vulnerable groups

• Developing awareness on social health protection from insured population and employers

• Reaching administration efficiency in a public institution

Conclusions

• It’s not “How much” we are spending, but “HOW we spend”

• Other sectors are critical (Social Determinants of Health)

• Technology/telemedicine has to play a key role

• There is enough robust growth to gunner change BUT equity is important

• Increased younger age population will “demand less health care” –(except the under 5 age group) – (dome shaped demand function)

• UHC as a path and not a goal has to be defined

Conclusions

Countries must aim to reach BUT:

Services must be meaningful

Continuum of care must be assured i.e. from prevention, promotion, rehabilitative and urgent medicals services

Services must be prioritised and expanded e.g. maternal and child health services must be prioritised and then plan to expand

Research and Emerging gaps

Research and existing evidence University of Zambia

Research and Evidence – Universal Access to

Health Care

Bona M Chitah,

Department of Economics,

The University of Zambia

BM Chitah - UHC and Research Gaps 90

Interpretation or Implications of Conceptual Foundation

• “UHC establishes what is to be achieved but says little on how to

get there, and even though there may be a few features

commonly associated to UHC and a few paths that do not seem

to lead to UHC, it does not fully clarify what can be considered

a UHC effort.”


Concepts (WHO/EIP/MHI)

• Health supply side terms

– Availability

– Affordability

• Health demand side terms

– Utilisation

– Acceptability

Access =

how much a population can reach health

services

Coverage =

the share of a population eligible (beneficiaries) for a set of

interventions

Patients and population


Historical context – Models of Primary Health Care

Comprehensive Selective Medical model

View of health Positive wellbeing Absence of disease Absence of Disease

Locus of control over health Communities and individuals Health professionals Medical practitioners

Major focus Health through equity and

community participation

Health through medical

interventions

Disease eradication through

medical interventions

Health care providers Multidisciplinary teams Doctors plus other health

professionals

Doctors

Strategies for health Multi-sectoral collaboration Medical interventions Medical interventions

Rogers W. & Veale, B. (2000).

Historical Context

• Comprehensive Primary Care and Health for All

• Alma – Ata (1978)

• PHC – Now more than ever (2009)

• Criticisms – failures – successes?


Factors and Rationale for UHC

• Health status – slow progress in differences between different

geographical regions

• Growing inequities intra-country and inter-country both in terms

of health outcomes and heath care resources

• Increasing financial risk and health induced impoverishment –

financially induced and poor – health – productivity

consequences

• Poor quality health care


Methodology

• Purposeful

• Selected review (systematic)

• Search terms: “universal access coverage” filtered by “evidence”

• Limited number of studies evaluated – requires further work


UHC – Definitional Issues

• Access to provision of and utilisation of health care services

• Where needed when needed,

• Required quality and standard

• Without unnecessary and un-affordable barriers• Summary: Services accessed by all, meeting health care need of population,

interacting and leading to,

• improved population health

• Access to health care

• Financial risk protection

• i.e. through better outcomes, outputs, processes, systems and inputs


Policy and Research - Concept

• Health policies - purposeful and deliberate actions through

which efforts are made to strengthen health systems in order to

promote strengthen health systems whilst also showing how

population health.

• Its multi-discilinary disciplinary research field, distinguished by

the issues and questions addressed through the research rather

than by a particular disciplinary base or set of methods;


Health Systems Research (and Policy)

• Includes qualitative and quantitative investigations and inquiries

into determining and analysing data and information on health

services; revention; promotion of health in general;

• Includes global and international; national and sub-national

issues over health systems

• How policies are developed and implemented and the influence

that policy actors have over policy outcomes – it addresses the

politics of health systems and health system strengthening;


Translation of Concepts, Policy, Strategies and Implementation into

Basis For Evidence

• Health system: people, institutions, resources, policies and

activities serving the primary function of promoting and/or

maintaining good health while promoting availability of quality

care and protecting population against financial cost of care

• Six core factors: Leadership and Governance; Service Delivery;

Health Human Resources; Health Information Systems; Medical

Products, Vaccines and Technologies; Health Care Financing


Inter-Relationships and Knowledge Gaps

• Health System and links towards improving and maintaining:

• Utilisation;

• Health Care Need and

• Quality of services provided efficiently to generate desirable outcome, responsiveness and financial protection


Leadership; Governance

Information

Medical products; technologies

Service delivery

Human Resources in Health

Financing – Collection, Pooling, Purchasing

Utilisation

Health Care Need

Quality of Service Delivery

Efficiency – efficacy, CEA

Health Outcome –level and equity

Responsiveness of service provision

Financial Protection


Health Systems Health Policy and Environment

Public Health Linkages HardwareStructure

TechnologyResourcing

Organisation

SoftwareValues; Norms; EthicsActors; Relationships

System Functioning - Policies,

Strategies, Activities, Evidence

and Change

Content &InstrumentsActors, Power& PoliticsInstitutions, Interests

GLOBAL AND NATIONAL INTERESTSBM Chitah - UHC and Research Gaps 103

Health Systems and UHC

• Design and functioning of health system- evidence and areas required

• Affordability of financing models/strategies

• Determination of health need – extent, priorities, interventions/services

• Access

• Prioritisation of:– Socio – economic sub-populations

– Benefits packages; interventions and services


Health Systems: Governance and Organisation

• Resource mobilisation – collection, pooling, purchasing

• Design of health systems and health outcomes – determining

causal linkages and understanding how to improve efficiency in

process


Governance and Organisation

Design and effects of UHC Models

• Beveridge Model – general revenue funding model (tax based); public

provision of services

• Bismarck Model – labour market based and dependant extensively on

labour market segmentation and payroll taxes by consequence

• Distinguishing features:

– Arrangements of benefits

– Organisation of providers


• Purchasing and payment modes for services

• Hybrid of Beveridge and Bismarkian?

• Revenue Collection – Pooling and Prepayment mechanisms

dominant – Can prepayment and pooling, achieve greater

impact than alternatives

• Coverage of socio – income groups – who are beneficiaries


• What extent are services accessed and distributed across

population groups

• Costs, institutional framework and efficiency


Access and Utilisation…

• Access in health care may be defined as a measure of potential and actual entry for a given population into the health system. Its determined by the interaction of the characteristics of the health care system and the characteristics of the potential user (Khan and Bhardwaj 1994).

• Five dimensions of access: availability, accessibility, accommodation, affordability, and acceptability.

• improving affordability will not necessarily improve access and utilization if the other dimensions have not also been addressed

• Financial protection; health status


Note…Difficulty with identifying UHC attribution

• Establishing the causal effect of an intervention requires mimicking a counterfactual situation (what would have happened in the absence of the intervention?) to rule out other factors that may simultaneously affect the outcome of interest.

• Counterfactual is impossible to observe in reality, it is usually estimated by using comparison groups. Therefore, an impact evaluation will typically analyze a group composed of those who participate in (or are affected by) the intervention being evaluated (also called the treatment group) and at least one comparison group (also called the control group).


• Endonegeity: Controlling for observed and unobserved differences when

evaluating the impact of UHC is key for an accurate assessment of the

cause and effect relationship

• Bidirectional causality between health status and UHC schemes:

• The bidirectional causal link between health status and UHC will make it difficult to identify the impact of UHC on health status unless either coverage is completely random or the data on health status prior to the intervention are available to correct the problem.


• The evidence of the impact of UHC schemes will probably be available for only some

schemes, particularly those that are still in early transition periods. Furthermore, there will

probably be no causal evidence of the impact of UHC systems in certain countries (for

example, little or no information exists on the impact of Chile’s social security system or

for certain types of UHC systems such as those that automatically entitle the whole

population to the benefits without any formal enrolment procedure, as was done in

Sweden or Spain)


Access, health status, and financial protection depend on much more than UHC.

• When evaluating the impact of UHC schemes on access and

financial protection, it is necessary to have a thorough

understanding of the many other determinants of each of these

performance dimensions. Results may be interpreted erroneously

when ignoring them.


UHC and Health Status Outcomes

• When selecting health status variables to measure the impact of UHC

schemes, care should be taken to ensure that a clear relationship exists

between access to health care and the health status variables being

considered, Levy et al. (2001)

Link Between Interventions and Outcomes

• The program’s theory of change should be explicitly stated when researching

UHC schemes, and the outcomes should be carefully chosen according to that

theory of change. Programs should not be evaluated based on outcomes

that are not affected by the intervention.


Methods

• Study design. The key weakness of the evidence is the flaw of many

study designs; standard regression or descriptive statistics only to explore

causal relations.

• No or very few randomised studies

• There is still a long way to go to have an extensive and robust evidence

base on the impact of UHC-like interventions


Research

• Expanding Coverage

• Which models work better (efficiency, equity, coverage)

• What is ideal or critical institutional framework and systems

required to ensure organisational, stewardship, support and

technical guidance and oversight exist

• For instance what is capacity to set priorities for benefits

package – services to be provided


Ethics of public health practice

• What and which services shall be provided and why

• What is the basis of doing what we do and is this affected or

does it affect how resources are distributed, access is shaped

and determined and services are provided? e.g. does an

objective utilitarian position matter from a positive egalitarian

and what are the implications


Health Care Financing

• Fee – for service = cost escalation => cost containment measures but

these negatively affect coverage and financial risk protection

• Equity

• Resource mobilisation (vertical versus horizontal equity), macro

economic growth and capacity, feasibility – issues of actors, political

positions

• Risk pooling

• Efficiency (cost – effectiveness)

• Purchasing


Pooling and Purchasing (Redistributive functions)

• Experiences of cross – subsidisation = rich and poor; (low risk) young and

old (high risk)

• Incrementalist approach – fragmentation of pooled resources and

management of pools

• Undeveloped formal labour market; size and capacity of labour market

• Consideration of “special” groups as incremental strategy is adoped –

equity and access consequences – political and ethical considerations


Human Resources for Health (health workforce)

• Access – infrastructure, technology, medicines and medical

supplies, ,governance = human resources for health to turn

processes, inputs into outcomes together with the households

• Balance distribution of health staff

• Provide incentives (financial and non-financial)

• Private and Public sector conflict


Areas where some results known

• A majority studies that analyse impact of UHC schemes on access and

that belong to the two top quartiles find favourable and statistically

significant impact of UHC schemes. This suggests that sufficient evidence

exists indicating that UHC schemes do improve access.

• Changing impact across outcome variables. Wagstaff and Yu (2007)

find positive impacts of UHC scheme on use of specific services (hepatitis

B immunization and the incidence of nontesting of suspected TB patients),

but no impact on more general measures of outpatient and inpatient

utilization.


• the general health insurance (GHI) program in Ecuador “is strongly

associated with the use of curative health care, but does not seem to

influence the use of preventive care”

• Substitution or increase in utilization? in some cases, UHC schemes

have an impact on the type of care used—changing from self-

medication or alternative medicine to formal care. In some cases,

UHC schemes have an impact on the type of provider chosen rather

than on utilization levels


• Impact on access only by means of improved affordability? UHC

schemes focusing on the reduction of financial barriers to access are not

expected to improve other dimensions of access beyond affordability.

(Can there be externalities)


Financial Risk Protection

• Overall impact. The impact of UHC schemes on financial protection is less

often studied than their impact on access;

• Results indicate that UHC schemes may reduce out-of-pocket

expenditures, and sometimes prevent catastrophic expenditures and

impoverishment

• In some cases, the results are mixed; In general, much more research is

needed in this field since most studies rely heavily only on conventional

measures of financial protection (out-of-pocket/catastrophic expenditures

and impoverishment).


What measures do not do….

• Fail to capture cost barriers to access - categorize those who cannot afford care as spending little or nothing on care assuming them (erroneously) as financially protected;

• Do not include other health-seeking related costs beyond direct payments, such as transportation costs

• Do not capture other strategies to cope with costs of illness such as reduced household consumption of other goods and services or increasing debt to finance health expenses;

• Do not include indirect costs such as income loss due to illness


• The link between financial protection and utilization- financial

protection is meant to be achieved primarily by reducing payments at the

point of service. The price subsidy is expected to—increase demand and

improve access to health services

• outpatient and inpatient care- greater benefits on inpatient care.


Health Status

• A majority of inconclusive studies. Several studies cannot find

conclusive evidence on the impact of health insurance when they

use health status measures available

• The evidence on the marginal impact of individual design features and the usefulness of impact evaluation evidence to date for policy guidance. Little known on the marginal contribution of the impact of individual design features of the UHC scheme


Other

• Balance – Supply side and demand side synchronisation and results

• Purchaser – Provide Split (Performance based financing)

• Is scheme welfare increasing – do the gains outweigh the inefficient moral

hazard spending.


Research and Emerging gaps

Defining Zambia’s Proposed SHI Package National Health Insurance Coordination Unit

SERVICE PROVISION UNDER THE PROPOSED NATIONAL SOCIAL

HEALTH INSURANCE SCHEME

DR. MPUMA KAMANGA

NATIONAL HEALTH INSURANCE CORDINATOR

MINISTRY OF HEALTH

130

30th June, 2015

ADVOCACY SYMPOSIUM ON UNIVERSAL HEALTH COVERAGE

Theme: “ Where are we & where are we headed?”

OUTLINE

Background

Context of reforms

Universal Health Coverage

Designing the Benefit Package

National Social Health Insurance Scheme- Main Reform features

BACKGROUND

Zambia is in the advanced process of implementing a National Social Health Insurance Scheme (NSHI) as a

mechanism to complement progress towards UHC

Currently only 3.9% of the population has any form of health insurance coverage

SHI is aimed at ensuring that:

All Zambians, are covered in a phased approached, and irrespective of their socioeconomic status have access to

quality health care

Quality health services are delivered equitably

The covered population does not pay for accessing health services at point of use

The covered population has financial risk protection against catastrophic health expenditure

THE THREE DIMENSIONS OF UHC

Universal health coverage (UHC) is defined as all people receiving quality health services that meet their needs without

being exposed to financial hardship in paying for the services

HOW TO MOVE IN THE DIRECTION TO UHC?

Expand services covered

– Which services?

Include more people into coverage

– Where to start and who will be eligible?

Reduce out-of-pocket payments by patients

– How to pre-pay more into a pool?

THREE-PART STRATEGY

Categorize services into priority classes. Relevant criteria include those related to cost-

effectiveness, priority to the worse off, and financial risk protection.

First expand coverage for high-priority services to everyone. This includes eliminating out-of-

pocket payments while increasing mandatory, progressive prepayment with pooling of funds.

While doing so, ensure that disadvantaged groups are not left behind. These will often include low-

income groups and rural populations.

SERVICE SELECTION CRITERIA

Careful selection of services is crucial for fair progressive realization of UHC

– Cost-effectiveness – Prioritizing services in order of their cost-effectiveness will provide the

largest possible sum of health benefits for a given budget.

– fairness recommends priority to services benefiting the worse off.

– financial risk protection – Financial risk protection is a key rationale for pursuing UHC

DESIGNING THE BENEFIT PACKAGE

Defined list of conditions funded through scheme unless on exclusion list.

Standard treatment guidelines for defined list of conditions/ common conditions.

Guidelines should define disease severity and the levels at which this should be managed.

Medicines should be linked to this clinical guideline – EML

SELECTION OF BENEFITS

Burden of Disease

Availability of services

Cost-Effectiveness

Safety

Quality

Appropriateness

Financial Protection

Comprehensive package across all levels

MATCHED BY

Strong emphasis on PHC, including prevention and health promotion (vs hospicentrism )

Prioritisation of services

Clinical guidelines, EDL, technology assessment

Gate-keeping

Strong referral systems

Need to manage progressive realisation of this package

Need to resist political pressure for excessive hospital care

WHICH SERVICES?

The public sector is the foundation for National Social Health Insurance Scheme

PROVIDED THAT

Strengthened :

Infrastructure & Equipment

Human resources (especially rural recruitment and retention)

High quality information system and ICT

Improved access, quality and efficiency

WHICH PROVIDERS? (1)

Private sector plays an important role (esp. GPs, private clinics, hospitals, pharmacies)

PROVIDED THAT

Single payer (risk pooling, purchasing power, comprehensive planning)

Price regulation

Active purchasing

Provide equivalent services

WHICH PROVIDERS? (2)

‘Incentivize health not services’

Reward good performance

Fee-for-service should not be the main mechanism

Capitation payments for PHC (plus some fee-for-service to incentivize prevention and

promotion?)

Global budgets for hospitals -> case-based payments (within global budget)

WHICH REIMBURSEMENT MECHANISMS?

NATIONAL SOCIAL HEALTH INSURANCE

VISION

Establish a High Quality & Efficient National Social Health Insurance Scheme:

Covering the whole population in a phased manner according to a defined time frame

Allowing both public and private health care providers from different health sectors to contribute in services

provision, based on quality & financial efficiency

Comprehensive Benefit package

Based on payer / provider split

Financially sustainable and administratively efficient

POLICY

The Rationale and need for a National SHI Scheme has been included in;

National Health policy 2012

Revised Sixth National Development Plan (SNDP)

National Health Strategic Plan (NHSP) 2011-2016

National Social Security policy and Implementation plan 2014

GOALS

1. To Achieve Universal Access to Quality health Care

2. To Improve the Quality of Service Delivery (Clean, Caring, Competent)

3. To Increase Resource Envelope, efficiency and ensure financial Sustainability

4. To provide financial protection from improvishment and paying for services at time of illness

MAIN HEALTH REFORM

147

Creation of a single Fund that is publicly owned and administered to:

Pool collected revenue derived mainly from general taxes and supplemented by mandatory earmarked payroll-linked contributions :

Strategically purchase personal quality health services from contracted public and private providers based on a specified service entitlement on behalf of the entire population

ALIGNMENT OF POOLING AND PURCHASING

FUNCTIONS

148

There will be one single institution that will pool funds and risks and purchase

services(Purchaser-Provider split)

Requires Legislative reforms through enactment of a bill and subsidiary statutory instruments

Single Fund/ Purchaser will contract with public and private providers

Standardized contracts for the various services (levels of care)

ALIGNMENT OF POOLING AND PURCHASING

FUNCTIONS

149

Accreditation requirements for all providers to be contracted

Certify for quality norms and standards

Accredits for performance

Post accreditation, quality monitoring

Reimbursement strategies to deploy standardized tools:

linking payments to performance and quality targets

capitation

Case-mix global budgets to DRG’s

Governance and Management Reforms in Public Sector facilities

(Decentralization, accountability and autonomy)

KEY FEATURES OF THE NATIONAL SOCIAL HEALTH

INSURANCE SCHEME

PROPOSED FRAMEWORK FOR ZAMBIA

SHI to cover all Zambians, adopting a 3 phase approach:

1. Very poor (100% GRZ for those receiving Social Cash transfers ) and Civil servants &

Public Workers

2. Private formal workers

3. The non poor informal population

WHO ARE THE BENEFICIARIES?

The registration is household based

This includes:

The contributing member

One spouse

All children below 18 – biological and adopted

Another 4 dependents

A household is defined as a person or a group of persons, related or unrelated, who live together and share common cooking

and eating arrangements.

POPULATION REGISTRATION

Members will be provided with a card to facilitate identification, eligibility verification at service provider level and

access to insured services

The cards will have unique and smart identification features (e.g. Unique ID numbers, Biometric capability will be

considered)

Benefits will be portable in cases of emergency, transfers, referrals, and migrant labour throughout the country in

accredited facilities.

NSHI cards for all population segments will be the same

avoid the stigmatisation of subsided households

WHO WILL MANAGE THE SCHEME?

The Scheme will be managed by an semi-independent body created through enactment of the Bill

Single Funder, publicly administered and separate from Providers

Close collaboration with regulatory bodies to enforce quality standards

Principle role: register members, issue membership cards receive funds, pool and purchase and contract quality

services on behalf of members

The scheme will not manage any health facility directly

Scheme will be publicly administered as a single purchaser with sub-national offices to negotiate and contract

accredited health providers (public and private)

Control measures will be put in place to ensure compliance with contribution collection and costs control (such as

provider payment mechanisms)

Administrative costs are to be limited to 10% of the total expenditures in the medium term

HOW WILL THE SCHEME IMPROVE THE QUALITY OF HEALTH SERVICES?

Specific mechanisms are considered to link payment to the providers to improved quality of care:

Accreditation,

Clinical audits,

Reporting requirements,

Performance based payment,

Guidelines on utilization of contribution revenue at provider level – to ensure the majority contribution

revenue will go to quality improvement.

Contracting mechanisms will bind accredited providers to the agreed quality mechanisms

Increased Competition between providers as Insured will have choice

HOW WILL THE SCHEME IMPROVE THE QUALITY OF HEALTH

SERVICES?

Set-up of a Complaint committee is proposed in the Bill (+ Ombudsman)

The payment of contribution will also give the patient a stronger voice to complain if not satisfied with the quality of health care.

provide initial investment for health care infrastructure and equipment (both public and private providers)-e.g. in the form of loans

SHI will bring ADDITIONAL financial resources to the Health sector.

The SHI contribution revenue will NOT replace the existing Government allocation to the health sector

WHAT IS THE BENEFIT PACKAGE?

COMPREHENSIVE BENEFIT PACKAGE:

Primary, Secondary, Tertiary Levels and specialized health care

Promotive, Preventive, Curative and Rehabilitative care

Consultations

Essential Medicines (including at Accredited Pharmacies and Chemists)

In-Patient & Out-Patients services,

Surgeries,

Diagnostic services & Screening Tests (Labs, X-Ray, CT Scan, MRI),

Oncology Treatment (Cancer Disease)

Pediatrics, Maternity care,

Physiotherapy, dental services, Vision care,

Annual physical check-ups, Immunizations

Flying Doctor service

Ambulance and Referral Services

Mobile Services

WHAT IS NOT IN THE BENEFIT PACKAGE? - EXCLUSION

Cosmetic surgery and aesthetic treatments and associated costs

Medicines not registered with the Zambia Medicines Regulatory Authority (ZAMRA)

Trans-sexual surgery

Treatment of infertility and artificial insemination

Spectacles and artificial lenses (except if medically required)

Experimental Treatment

Treatment of occupational accidents and illness – to be covered by Workmen’s Compensation Fund

Overseas health care services for medically necessary diagnoses and treatments.

Mortal remains repatriation

THE ZAMBIAN ENVISAGED MODEL OF NATIONAL SOCIAL HEALTH INSURANCE-

SUMMARY

Mandatory Enrolment

For all citizens and legal residents

No financial barriers at point of access of care

Single Payer Payment System

NSHI will be the only legitimate insurer of NSHI

benefits

Contracted service Providers paid on negotiated

reference price list

National Administration of the Scheme

Administered by independent agency through

enactment of legislation

Contributions into the NSHI Scheme

Employers and Employees

Self employed

Vulnerable covered by GRZ subsidies

Benefits

Comprehensive Benefit package has been defined

accredited Public and private providers will be

contracted

Cover will be for contributing member, spouse, all

children below 18yrs and 4 other dependents

Thank you

presentations during a national universal health coverage...

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