Improving Access through Effective Health Financing

Photo: © Tuggela Riddley/IRIN

The last World Health Report published some quite shocking numbers: 1.3 billion people are excluded of health services and 1 million people impoverish every year because they need medical treatment. The report with the title “Health System Financing – the Path to Universal Coverage” focused on one important element of a broader issue, how to strengthen health systems. (WHR 2010)

The financing of health systems is a key topic of political debates – not only in developing but also in industrialized countries. Therefore it was incomprehensible that there was no reaction on the report in a wider Swiss public. With this year’s spring symposium the Swiss Tropical and Public Health Institute (Swiss TPH) jumped into this silence bringing together different experts working in the field of health economics, health politics and international health cooperation. “Improving Access through Effective Health Financing” was the title of the conference, which was focusing mainly on introducing health insurance systems as an instrument to pool and share health expenses.

The Spring Symposium was opened by David Evans, Director of the Department of Health Systems Financing in the Cluster on Health Systems and Services at the World Health Organization. As the lead author of the World Health Report 2010 he was the very right person to introduce into the theme and to give an overview on the actual state of the debate.

Towards universal coverage

The fact that worldwide millions are suffering financially when they get ill is of course very disturbing. Having no access to health services and living in poverty are strongly linked. Evans pointed out that the exclusion is also linked to other factors outside the health system. However, one correlation seems to be clear: If the health financing system does not work, the other elements of the health system will not work either.

Positively said: If a country can find a stable financing system for health services which responds in an appropriate way to the demands of the population and does not exclude people on the grounds of their socio-economic, cultural or gender status, the system finds itself on an adequate – not necessarily sufficient – way towards universal coverage as defined by WHO.

To reach universal coverage three dimensions of the health systems have to be addressed:
1. Population, with the aim of including the whole population
2. Provision of health services, with the aim to include missing services
3. Financial protection, with the aim to reduce out of pocket payments and increase solidarity-based funding of services.

The focus of the symposium was laid on the third dimension for reaching universal coverage – on effective financing instruments for enabling the health system to provide good quality services. Such instruments may address either the supply side or the demand side of the health system.

Vouchers – incentives on the demand side

Demand side financing has the purpose to increase the client’s power as consumer of health services. One instrument to do this was presented by Wolfgang Bichman of the KfW Entwicklungsbank in Germany, who shared his experiences with voucher systems. In the programmes financed by KfW vouchers are distributed to parts of the population in order to improve their access to specific services such as reproductive health services or diagnosis and treatment for sexually transmitted diseases (STD).

In Uganda or Kenya vouchers are provided to specific population groups (mostly to poor women) with the intention to empower them to choose between different health service providers and to incentivize them to utilize such services.

The money the accredited service providers earn through the voucher systems contributed to their income and is used for investments into their services, as the example of the Kenya Voucher Scheme 2006-2011 has shown. Such investments are expected to have a positive effect on the strengthening of the whole health system.

Transforming existing funding systems

Improving health financing by introducing insurance schemes is certainly an important way to go. The debate at the Symposium showed that this is not a quick fix solution for reaching universal coverage. In industrialized countries, where the health system is normally financed by taxes, often in combination with a health insurance scheme, it took more than one hundred years to develop a more or less stable health financing system, which is integrated into a larger social protection system.

Against the background of this long social and cultural development approaches trying to build up insurance schemes take time and need to be adapted to the specific social and economic conditions of the respective country. Ideal and “fit-for-all” solutions are not available, but rather a mix of approaches is presently being implemented worldwide, as shown in the World Health Report 2010.

Manfred Stoermer analyzed on behalf of the Swiss TPH the Community Health Funds (CHF) in Tanzania and discussed options of how they can be improved. CHF form part of Tanzania’s health financing system. Introduced in 1996 they are decentralised prepayment schemes, administered by the district councils. Against paying a modest premium of 5 – 10 US Dollars per household members have access to health care on the primary level.

The analysis done by the Swiss TPH revealed various challenges on design, enrolment, service and sustainability aspects of the CHF schemes. Swiss TPH will support the Ministry of Health and Social Welfare in the redesign of CHF with the aim to strengthen them organisationally, make them more responsive to the population’s needs, and in the medium term integrate them into the National Health Insurance Fund.

Building up health insurance systems

At the Symposium different speakers shared their experiences in building up health insurance systems on a national, or local level. Caroline Jehu-Appiah of the Department of Health Services in Ghana presented the experiences of introducing a national health insurance scheme (NIHS) in Ghana since 2003. For Tanzania, the Director General of the National Health Insurance Fund (NHIF) Emmanuel Humba, presented the experiences, successes and challenges with building up this national scheme. The NHIF has grown to a significant player in the Tanzanian health financing system, and with its support to the CHF schemes renders important contributions to the process of reaching universal coverage for the country. Emmanuel Humba and Caroline Jehu-Appiah both pointed out the crucial importance of having the political will behind such an institution.

The figures of the Ghana example show the success of the NIHS: Almost half of the population is already covered against the risks of illness. Included are not only persons of the formal sector, but of the urban informal and rural sectors as well. The effect on financing of the health system is impressive: the NIHS has increased the financial resources available for the health sector significantly, and thus enabled Ghana to attain its Abuja target.

These examples clearly show that the introduction and expansion of health insurance schemes may make important contributions for health systems through mobilising funding, protecting people from catastrophic expenditures, and, last but not least, through providing them a voice through which quality concerns may be negotiated with health care providers. As the examples of Ghana and Tanzania show, and the World Health Report 2010 illustrates, governments worldwide are taking up this task of organising effective social protection mechanisms for their populations in their health sectors.

Support of developing countries

The World Health Report also points out the need of many countries to be supported in their endeavours for strengthening the financial basis of their health systems. The German Development Cooperation, represented by Jenni Kehler of “Gesellschaft für Internationale Zusammenarbeit” (GIZ), and the Swiss Development Cooperation (SDC), represented by Debora Kern, illuminated at the Symposium what their Governments are doing in this direction. Both agencies are members of the “Partnership for Health Protection” Initiative (P4H). This programme, lead by the WHO, was initiated at the G8-Summit in Heiligendamm in 2007, and includes the Governments of Germany, France, and Switzerland (since 2011) and international organisations such as WHO, Worls Bank, and ILO.

The P4H-Initiative intends to reduce the number of people in developing countries suffering from impoverishment because of getting ill. With the approach of social health protection governments are offered support in their own reform agendas which often aim at building up systems of risk-pooling and prepayment , be it through social health insurance schemes or tax funding, or a mix of both.

P4H at the moment renders support to Cambodia, Uganda, Kenya, Sri Lanka, Mongolia and Senegal. The focus lies on knowledge sharing and support of the development of Health Financing Plans and Social Health Protection Systems.

SDC’s Debora Kern pointed out that the empowerment of the service users is a crucial factor. To this end, both the demand side and the supply side should be involved from the very beginning of a programme. Another important aspect, which was addressed by different speakers at the symposium, is the challenge of really reaching the poor. For this objective, providing tax funded government subsidies targeted to the poor seems to be the crucial complimentary factor to membership contributions within social health insurance systems.

Although the focus on health financing addresses an important aspect for strengthening health systems, this of course is not sufficient. Don deSavigny of the Swiss TPH renders in his contribution a note of warning to concentrate too much on one or two aspects of the system. Complex systems are dynamic, constantly changing and at the same time resistant to changes. This is why social health protection does not guarantee improved access, and improved access is not enough to reach universal coverage. DeSavigny summarised: “Achieving Universal Coverage means that health insurance must be part of an integrated suite of health system strengthening interventions that are understood, organized and evaluated as a whole system.”

*Manfred Stoermer, M.A. Public Policy and Management, is Head of the Health Systems and Economics Unit of the Swiss Centre for International Health, a department of the Swiss Tropical and Public Health Institute (Swiss TPH). Before joining the Swiss TPH, he worked as a health financing consultant in numerous assignments with multilateral (EU) and bilateral agencies (GTZ, InWent, FAKT, Lux-Development, Swiss Development Cooperation, Novartis Foundation) in Africa, Asia, and Eastern Europe. He was the coordinator of the Swiss TPH Spring Symposium 2011. Contact: manfred.stoermer@unibas.ch

*Martin Leschhorn Strebel is member of the management board of the Network Medicus Mundi Switzerland (MMS) and editor of the bulletin. Contact: martin.leschhorn@medicusmundi.ch