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Salman Rawaf
The 5th International Conference on Primary Care/Family Health“Primary Care: Now more than ever”, Rio de Janeiro, 24-26 March 2010
WHO Centre
Imperial College London
Ref: 36/2010
Contents:1. Health Finance
2. Health Systems and Finance
3. Funding Health Systems
4. Effectiveness of Primary Care
5. Setting Objectives and Targets
6. Now, more than ever
© WHO Centre, London
WHO Collaborating Centre, London
WHO Centre, Imperial College London
Health System Goals
Better Health
Responsiveness to person’s needs
Financial Protection against health care costs
WHO Centre, Imperial College London
Universal
Coverage
Liberal
Medicine
Resilience of
Insurances
The Choice
of Doctor
Different Priorities
WHO Centre, Imperial College London
French patients consume twice
more drugs than their European
counterparts
The Choice
of Doctor
© WHO Centre, IC London
Funding Health Systems
© WHO Centre, IC London
Health Finance
© WHO Centre, IC London
Methods of Raising, Pooling and Allocating
Capital (Developmental) and Revenue
(Recurrent, Operational) Funds in equitable
and efficient ways to meet the population’s
health needs
Financing Health Systems
General Taxation (Sweden, UK, Italy, Spain, Canada, Australia)
Social Insurance (France, Germany, Austria, Belgium)
Private Insurance (USA)
Out-of-Pocket
Mixture© WHO Centre, London
Health Systems
NHS (Sweden, UK, Canada, Australia)
Social Insurance (France, Germany)
Free Market (USA)
Mixture of the three
+ Medicare & Medicaid (elderly, disabled + Poor)
© WHO Centre, London
Health Systems
National Health Service (Sweden, UK, Canada, Australia)
Social Insurance (France, Germany)
Free Market (USA)
Mixed
PHC Accountability Gov. Role
PHC-
led
Public Strong (if not devolved)
Weak
(Improving)
Public/
Insurance
Weak-
Strong
Very
Weak
Insurance/
shareholders
Very
Weak
variable variable variable
© WHO Centre, London
General
Taxation
Soc Insurance Private
Insurance
OOP/Co-pay
Sweden 84 16
Australia 70 - 8 16
Canada 69 1 11 17
UK 82 10 4 6 Prescriptions
France 3 74 13 10
Germany 6 69 7 13
USA Medicare & Medicaid
(Elderly, Disabled, Poor)55 ?
Public % Private %
Source of Health System Finance: Global 05/6
© WHO Centre, London Source: S Rawaf ICL
General
Taxation
Soc Insurance Private
Insurance
OOP/Co-pay
Sweden 84 16
Australia 70 - 8 16
Canada 69 1 11 17
UK 82 10 4 6 Prescriptions
France 3 74 13 10
Germany 6 69 7 13
USA Medicare & Medicaid
(Elderly, Disabled, Poor)55 ?
Public % Private %
Source of Health System Finance: Global 05/6
100% access
1/6 of pop. with no insurance
© WHO Centre, London Source: S Rawaf ICL
Health System Funding: General
WHO Centre, IC London S Rawaf 2009
LIC MIC HICPrivate OOP
Private Pooled
Government
© WHO Collaborating Centre, London Source: Eurostat OECD
Professor S Rawaf
100(GDP)
289.3(GDP)
Health Spending in the ECC (Six Countries)
1965 = 100
4.9%
10.2 %
1965 2006
© WHO Centre, IC London
Australia: June 2009 Redesigning our health system to meet emerging challenges
1. Embed prevention and early intervention
2 „Next generation‟ of Medicare
“The Government will be responsible for bringing together
state-funded primary health care services and medical
services under Medicare to create a comprehensive primary
health care platform. This will include a focus on promoting
good health, early intervention and better managing chronic
disease.
3. ..........
© WHO Centre, IC London
Example:
Malaysia
© WHO Centre, IC London
40914589
5022
6068
70267593
10,442
11,92611,045
9,65810,606
13,393
10,602
8,494
60265494
5447472143774122
0
2000
4000
6000
8000
10000
12000
14000
16000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
RM
billio
n
Public Sector Private Sector
Public/Private Mix: Malaysia
© WHO Centre, IC London
Growth of OOP Spending: Malaysia
© WHO Centre, IC London Source: Rawaf, 2009
Market Regulations/ seamless services between primary & secondary services Professor S Rawaf
• Public Health & PHC
• Secondary + Tertiary Care
Funding4 Commissioning/ Contracting Provision
State Funding and Delivery * Regulations, Cross-cutting Issues, HRD, etc
H Insurance:
Employers
-Employers’
Contributions
(family-based)
- Gov Contribution
H.I.: Self Emply:
- Gov HI Sold \
(x% Cost)
-Identify % core
Subsidy
H.I.: General-Funded
-Unemployed
-Disadvantaged
- Elderly/Retired
--Refugees
- Disabled etc
Collect
ion
H Insurance (Funding) Agency/Authority
Public Hospitals
University Hoapitals
Private Hospitals
NGOs
OverseasProviders
Commissioning1 Acute Services
Commissioning2 Mental Health
CommissioningCommunity Ser
Other than PH & PHC
Contingency 3Fund
Malaysia 2009
© WHO Centre, IC London
Effectiveness of Primary care
WHO Centre, Imperial College London
Evidence shows:
The importance of a robust system of primary
care for health economies
High-quality health systems and healthy
populations require strong and effective primary
care services.
B Starfield, 1994, 2005
Weak PHC Countries
Strong PHC Countries
1970 1980 1990 2000
500
0
Countries shifted the focus of their health system from specialized hospital-based to PHC
1000
OECD Countries: Potential Years Life Lost (PYLL)
Source: B Starfield
© WHO Collaborating Centre, London B Starfield, 2005
Health Professional Supply & Child Survival
Source: Chen et al, Lancet 2004; 364:1984-90.
Densi
ty (
work
ers
per
1000)
Child mortality (under 5) per 1000 live births3 5 9 5
0
100 250
25
15
10
5.0
2.5
1
*186 countries
© WHO Centre, IC London
? Organisation
© WHO Centre, IC London Source: Commonwealth Fund, 2008
Australia Canada Germany NZ UK
Overall Ranking 2007 3.5 5 2 3.5 1
Quality Care 4 6 2.5 2.5 1
Right Care 5 6 2.5 2.5 2
Safe Care 4 6 3 4 2
Coordinated care 3 6 4 2 1
Pt Centered Care 3 6 2 1 4
Access 3 5 1 2 4
Efficiency 4 5 3 2 1
Equity 2 5 4 3 1
LH Productive Life 1 3 2 4.5 4.5
Health Expenditure P
Per Capita, 2004 $
2,876 3,165 3,005 2,083 2,546
High Performing Systems: Quality of Care
© WHO Collaborating Centre, London
0
20
40
60
80
100
120
140
160
180
1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9
England: Deaths due to Vascular Diseases
© WHO Centre, IC London
Setting Objectives & Targets
WHO Centre, Imperial College London
Public Health
InterventionsPersonal
Care
© WHO Collaborating Centre, London
National Institute for HealthPrevent Risk & Disease (PH + PC)
Reduce Risk & Maintain Low Risk
Reduce Admission (%)
Reduce Mortality (%)
Improve Quality of Life
WHO Centre, Imperial College London C Schoen et al, 2009
Primary care Doctors Role & Payment 2009
© WHO Collaborating Centre, London
The UK
Vascular Checks
© WHO Collaborating Centre, London
A single, universal, integrated
check for all aged 40 - 74
• Measure risk of
cardiovascular disease,
diabetes and chronic
kidney disease
• Set out how to reduce
risk/maintain low risk
• Offer tailored package of
prevention
© WHO Collaborating Centre, London
UK: Vascular Check
© WHO Collaborating Centre, London
• Offer 3m vascular checks a year
• Cost about £250m before savings
And each year will prevent at least:
- 9,500 heart attacks and strokes
- 2,000 deaths
- 4,000 people developing diabetes
Estimates
The UK Program will:
© WHO Centre, IC London
Now, More than Ever
WHO Centre, Imperial College London
Universal Coverage1
Universal Coverage reforms
• "Progressive" financing for health for all
– based on pre-payment and pooling mechanisms to:
• Ensure availability of services, and
• Eliminate financial barriers to access
• But that is not enough:
– mobilize beyond the health sector to social protection schemes– give visibility and voice to the invisible and voiceless– reach the unreached
© WHO Centre, IC London
WHO Centre, Imperial College London
Non-Communicable Diseases 2
The difficult adaptation to new challenges
2010
CVA
CHD
Cancer
WHO Centre, Imperial College London
© WHO Collaborating Centre, London
National Institute for Health
Worldwide: The 10 leading causes of Death2004
© WHO Collaborating Centre, London
National Institute for Health
Annual Deaths due to Tobacco Million
Projected Foregone National Income due to Heart Disease, Stroke and Diabetes
Brazil 2.7 49.2
China 18.3 557.7
India 8.7 236.6
Pakistan 1.2 30.7
Russian Federation 11.1 303.2
US$ Billion
Source: Preventing Chronic Disease: A Vital Investment, WHO 2005
200510 years
accumulated
© WHO Collaborating Centre, London
WHO Centre, Imperial College London
Technological Advances3
© WHO Centre, Imperial College London
Professor S Rawaf
Family Physician
Effective Gate-Keeping Function
Only Relevant referral
No Delay
Patient Choice
Follow-up
Cost-Effectiveness
Patient Satisfaction
Seamless Service
Hospital Reception
Hospital specialist
No Medication
© WHO Centre, London
WHO Centre, Imperial College London
Social Protection4
Every year, globally, 150 million people suffer financial
catastrophe and 100 million people are pushed into poverty
due to health spending
- 30,000 60,000 90,000
WPR
AMR
SEA
EUR
AFR
EMR
Number of people (1,000)
impoverishment
catastrophic
First do no harm!
© WHO Centre, IC London
High Costs = People Search for
Cheaper OPTIONS
© WHO Centre, London
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
% growth government health spending
% r
eduction U
5M
R 1
990-2
015
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
0% 3% 5% 8% 10% 13% 15%
5% economic growth
& 2.5% female education growth
& 2.5% roads growth
& 2.5% water & sanitary growth
& 2.5% growth in all
Investments are Needed
Across Many Sectors to Achieve MDGs
© WHO Centre, IC London Source: WB, GS
And Finally .......
Thank You