UNIVERSAL HEALTH COVERAGE

UP Devkota

HISTORY

• Socialist movement 1830’s

• Royal commission on Operation of the Poor Laws 1832

• Carl Marx (Das Kapital 1867)

• Liberal challenged by Labour (1906) - Welfare reforms

• National Insurance Act 1911 - David Lloyd George • Post – First World War

Serious social reform to avert communist revolt

THE BEVERIDGE REPORT 1942

• Giant Evils in society – Squalor, ignorance, want, idleness and disease

• RecommendationFlat compulsory national insurance scheme for Healthcare, unemployment and retirement benefit

• CautionMisuse of unemployment benefitInherent human laziness

THE NATIONAL HEALTH SERVICE

• Labour Party victory 1945 (NHS act 1946/47/48)

• Implementation 5th July 1948 (Aneurin Bevan)

• Welfare state – “Care from the cradle to the grave”

• Funding – General taxation + National insurance

• All municipal and charitable hospitals nationalised

Could war impoverished Britain afford it?

• The classic welfare state 1945-1980

88(13.06%)

119(17.66%)

190(28.19%)38

(5.64%)

239(35.46%)

United Kingdom

Education, £ 88bn Health, £ 119bn Social protection, £ 190bn

Defence, £ 38bn Others, £ 239bn

GOVERNMENT EXPENDITURE

86.03(16.63%) 33.52

(6.48%)

55(10.63%)

28.86(5.58%)

313.83(60.67%)

Nepal

Education, Rs. 86.03 bn Health, Rs. 33.52 bnSocial security and pension, Rs. 55.00 bn Defence, Rs. 28.86 bnOthers, Rs. 313.83 bn

SOCIAL WELFARE EXPENDITURE UK 2011-12

Benefit Expenditure (£bn)State pension £74.2Housing Benefit £16.9Disability Living Allowance £12.6Pension Credit £8.1Income Support £6.9Rent rebates £5.5Attendance Allowance £5.3Jobseeker’s Allowance £4.9Incapacity Benefit £4.9Council Tax Benefit £4.8Other uncategorized expenditure £4.7Employment and Support Allowance £3.6Statutory Sick/Maternity pay £2.5Social Fund £2.4Carer’s Allowance £1.7Financial Assistance Scheme £1.2TOTAL £160.2

NEPALESE REALITIES IN 2002

• GDP per capita $261

• Budget on health < 5% of the total ($2.30 per person).

• Total health expenditure

62.5% out of pocket

16.8% public expenditure

9% EDPs

HEALTH SECTOR FINANCING

Requirement Total National Spending

3

7

NO

MONEY

GovtEDP1.5

Pocket

Tertiary

Secondary

Primary Health Care Service

12 – 36 US $ / head

THE WAY FORWARD…• EHCS- government’s responsibility

• Secondary/tertiary care health insurance

FEASIBILITY WORK FOR HEALTH INSURANCE

• Positive attributes

• Risk sharing culture- guthi, parma etc

• Solidarity deep rooted in culture

• Health benefit payout NRs 1.2 billion

• Out of pocket spending outside the country NRs 2.3

billion

POPULATION EMPLOYMENT STATUS 2002

25%

7%68%

Private formalPublic formalSelf employed

PREPARATORY WORK• MoH invested on HR training

• Experts from DFID, ILO, WHO to help

• Invested on improving secondary and tertiary care

• Health Sector Reform Strategy

• Established health economics and financing unit

MAJOR FINDINGS AND RECOMMENDATIONS(ANDREW GREEN)

• Strong political commitment but volatile political stability

• Micro economic condition not conducive to nationwide social health insurance

• Formal sector (32%) too small to pool risks

• Unwillingness of Government employees (7%) to part with Medical Benefit Savings

• Prepaid and community health insurance could be piloted and scaled up

FACILITATION AND IMPLEMENTATION

• Orientation of insurance companies on health insurance

• Requested Bima Sansthan to regulate schemes

• Private companies requested to offer benefit packages

NO TAKERS!

MOH WENT ALONE…..

• Established Insurance Committees to split the provider and purchaser’s role at HF

• Chose Tikapur, Chandra Nigahpur, Mangalbare, Dumkauli and Katari for piloting

• Paid the insurance premium for the defined population

BENEFIT PACKAGEScheme Medicine Diagnosis Hospitalisation Transportation Total

Mangalabare PHC (with referral)

In-patient: NRs. 3,000; Out-patient: NRs. 1,000

Diagnosis: NRs. 5000; (50% co-payment in CT Scan and Endoscope)

Bed charge :NRs.1000; Operation: NRs.4000; operation material: NRs.1000; ICU: NRs. 4000

NRs.1000 way to facility only.

NRs. 20,000 for individual and NRs. 120,000 for whole family members.

Mangalabare PHC (without referral)

NRs. 3,000

Diagnosis: NRs. 3000; (80% co-payment in CT Scan and Endoscope)

  NRs. 500 one way for specific VDC depending upon case.

NRs. 6,000 per person.

PREMIUM

Scheme Category Amount of premium

Mangalabare PHC Referral 1400 for a family up to 6

Non referral 600 for a family up to 6

Dumkauli PHC General 700 + 50 for each additional member

Referral 1800 + 200 for each additional member

IMPACT• Service utilization increased three folds

• More poor and marginalised (10% Dalits and 41% Disadvantaged Janajati) were benefitted by the schemes in compared to private (2% Dalits and 36% Janajati)

• Cost recovery rate increased to 60% in 2006.

• Governance and accountability of health facilities improved

RISKS & CHALLENGES AHEAD

• Moral hazard (providers and users) and

• Adverse selection (more sick persons enrolled).

• Potential fiduciary risks

• Quality of care at the public health facility

• Intimidating growth of private sector

• Poor financial governance

Thank You