THE VIRTUOUS CYCLE OF NHI FOR UHC

INCREASING PREPAYMENTS AND IMPROVING

SERVICE DELIVERY
Sources: Presentation made in Amman, WHO EMRO 2014
Presentation made in Ho Chi Minh, 8th FTF, 2015
Disclaimer: The views expressed in this paper/presentation are the views of
the author and do not necessarily reflect the views or policies of the Asian
Development Bank (ADB), or its Board of Governors, or the governments they
represent. ADB does not guarantee the accuracy of the data included in this
paper and accepts no responsibility for any consequence of their use.
Terminology used may not necessarily be consistent with ADB official terms.

Maria Elena (Maya) Baltazar Herrera, FASP, PhD

Asian Institute of Management

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Outline

Context
The Challenges of UHC
Lessons from NHI Efforts
Moving Forward

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Widespread commitment to UHC

Solutions must address local realities

CONTEXT

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Globally each year:

150 million people face
Catastrophic expenditure
Financial
protection
100 million people face Impoverishing expenditures

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Source: compiled based on data from Xu et al. 2010

WHICH DIMENSION FIRST?

Which people?
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Cost Sharing

UHC Dimensions

Setting Targets
Analyzing Outcomes

Platforms for UHC?

NHS vs. SHI
Supply vs. Demand
SHI vs. NHI

Cost Sharing

UHC Dimensions

Setting Sectoral Targets

Analyzing by Sector Outcomes

Which people?
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Financing mix:
No country relies on a single source

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Financing mix:
No country relies on a single source

But financial sustainability is a

critical factor in successful
UHC!

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

The emerging consensus: First, achieve

breadth of coverage. Then build benefits and
increase financial support.

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

The Challenges are not new

Low income countries
tend to suffer from poor
tax collection
Their populations are hard
to tax
More rural
More informal employment

Implications for health

spending:
More private; more out-ofpocket; more regressive

Private as
Country Government % of total
income revenues as
health
group
% GDP
spending
Low

20%

53%

Middle

31%

43%

High

42%

33%

Source: Schieber and Maeda 1997

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Higher income associated with less out-ofpocket spending (OOPS).

Source: WHO estimates for 2011, countries with population > 500,000
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Where governments spend more,

patients pay less

Source: WHO estimates for 2011, countries with population > 500,000
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

The emerging consensus: First, achieve

breadth of coverage. Then build benefits and
increase financial support.

MANY COUNTRIES ARE LOOKING AT NHI

AS A KEY ELEMENT OF THE ROAD MAP TO

UHC.
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

PHILOSOPHY
& REGULATION

Conflicting Roles: Steward, Provider, Regulator?

Ineffective policies; regulatory & legal framework

Financing

DEMAND

SUPPLY
Poor Availability
Lack of Standards
Poor enforcement and selfregulation of quality
Low quality and efficiency
Unpredictable earnings
low investment & low
access to capital

Delivery

Limited savings
Low insurance cover
No pre-payment
No fund pooling
Low trust
High OOP
No money, no choice
PATIENTS

Double burden of disease

Poor information poor
Crowding and Gaps
decision-making Illogical care
Driven
Financers perceive high risk
utilization
by
Lack of access to capital
Poor health outcomes
RISK
All
Rights
Reserved.
Maria
Elena
Baltazar Herrera
Low Investment
(Maya)
Catastrophic
OOP expenses
INVESTMENT

VICIOUS
CYCLE

PHILOSOPHY
& REGULATION

Clear Role: Steward & Regulator

Clear policies; regulatory & legal framework

Prepayments secure financing, empower patients, drive availability and

quality, increase access to capital
SUPPLY

Availability matches Demand

Standards linked to pay
Improved quality regulation
Quality linked to demand
Improved quality & efficiency
Attractive earnings
incentive for investment

Financing
VIRTUOUS
CYCLE

Delivery

DEMAND
Contribution mandate
secures prepayment
funding stream
Fund pooling enables
social equity
Funded, defined
benefits enable choice
PATIENTS

Double burden of disease

Poor information poor
INVESTMENT
decision-making Illogical care
Sustainable, viable
Driven
utilization
enterprise model
by Elena (Maya) Baltazar Herrera
All Rights Reserved. Maria
Poor health outcomes
TRUST
Improved access to capital

Providing versus Stewardship.

Loevinsohn, 2000

Focus on results
Flexibility
Reduction of important aspects of corruption
Constructive competition
Improved absorptive capacity
Better distribution of health care workers
Managerial autonomy
Government focus on Stewardship
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Key Lessons

NHI, not just a collection of SHIs, provide an

integrated platform for influencing the health
care system
NHI shifts government to a stewardship role
NHI effectively secures some portion of
funding because contributions act as specific
taxation
NHI provides a mechanism to secure
government funding
NHI provides the ability to secure a fund
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

Key Lessons
NHI provides the patient with demandable
rights not just what is available. NHI gives
the patient power and choice.
NHI provides an effective mechanism for
targeting populations and conditions.
NHI provides the market with the SPACE to
respond to demand.
If you PAY FOR IT, they WILL BUILD IT.
This requires capacity-building! Dont forget
some health care costs are granular
All Rights Reserved. Maria Elena (Maya) Baltazar Herrera

THANK YOU!
Google me:
maya baltazar Herrera
maya@aim.edu
Facebook: teacher maya

Handbook of Global Public

Health in Asia
Routledge

Twitter: maya_aim

All Rights Reserved. Maria Elena (Maya) Baltazar Herrera