policy
Financing Health in the Post-2015 Era: Filling Gaps For Sustained Impact
July 2015 Suneeta Sharma,PhD Project Director Arin Dutta Kaja Jurczynska
Outline • What are we funding in health today? • Domestic resource mobilization: new energy in an old topic • Challenges to resource mobilization: complex disease burden • Raising resources by linking across sectors: the SDGs • Critical decisions towards Universal Health Coverage: raising and using resources wisely • Key considerations for allocating and spending resources
Development Assistance for Health (DAH)
Global Health Financing Sources
40B
Unallocable Other Debt Repayments Corp. Donations BMGF Private Other Other Govt. Australia Canada France Germany Japan Netherlands Norway Spain UK US
2014 US Dollars
30B
20B
10B
0B
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
SOURCE: Institute for Health Metrics and Evaluation. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. Seattle, WA: IHME, 2015.
Global Health Financing by Health Focus
40B
2014 US Dollars
30B
Unallocable Other SWAps NCDs Ebola Other Infectious Diseases TB Malaria Maternal Health Newborn and Child Health HIV/AIDS
20B
10B
0B
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
SOURCE: Institute for Health Metrics and Evaluation. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. Seattle, WA: IHME, 2015.
Domestic Resources for Health
HIV LIC
LMIC
UMIC
10%
22%
80%
35
30
17.2
USD Billions
25
20
15
10
5
0
8.7
8.7 3.7
9.7
5.5 2013 (Expenditures)
Lower Income
2020 (Resource Needs)
Lower-Middle Income
Upper-Middle Income
RMNCH + A 40
USD Billions
30
20
10
0
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Total Increment Financing (domestic financing, dev. asst. for health, including GFF Trust Fund and IDA/BRC Increment Domestic Financing Crowded-In as a Result of the GFF Increment Domestic Financing Related to Economic Growth Increment Resource Needs (after efficiency gains related to the GFF) Increment Resource Needs (no GFF)
70% of the annual incremental cost of health programs from 2015-2035 can be financed by domestic sources if 3% of GDP is allocated to health SOURCE: Lancet 2013; 382: 1898–955. Global health 2035: a world converging within a generation. World Bank. 2015. Concept Note: A Global Financing Facility in Support of Every Woman and Every Child.
Increasingly Complex Epidemiological Terrain in Low-Income Countries
Cause of DALYs (Share of Total, Over Time)
GLOBAL
SSA
ETHIOPIA
100
100
100
80
80
80
60
60
60
40
40
40
20
20
20
0
0
0
1990
2010
Communicable
1990
2010
Non-Communicable
1990
2010
Injuries
SOURCE: Institute for Health Metrics and Evaluation. The Global Burden of Disease: Generating Evidence, Guiding Policy. Seattle, WA: IHME, 2013.
How Does Health Fit Within the Sustainable Development Goals?
Dignty
People
Prosperity
Justice
Economic Development Human Rights
Planet
Empowerment
Higher Education
Stewardship
Improve Livelihoods
Improve Health and Survival
Lower Disease Transmission
*SDGs have been collapsed into several thematic categories developed by The Guardian.
Partnership
What Implications Do FP Investments Hold for the SDGs?
SDG 3: Ensure Healthy Lives
11,000 Children’s Lives Saved by 2020
Achieving Ethiopia’s FP goals in the Amhara region would save the lives of an additional 11,000 children by 2020
SDG 8: Promote Economic Growth & Productive Employment
12,000
Demographic Dividend
10,000
$8,748
Current USD
8,000
{
$11,288
$6,693
6,000 4,000 2,000 0
$907
$896
2010
2050 Base Case
2050 Econ Only
2050 Econ + Ed
2050 Econ + Ed + FP
GDP per capita in Kenya, by Scenario
Critical Decisions Towards Universal Health Coverage
Universal Health Coverage: Unpacking its Dimensions
Current Pooled Funds Heighth
Current Pooled Funds
th
Dep
Breadth
WHO IS COVERED? Equity Access Subsidizing Poor Geographcal Access Social Inclusion Cover Marginalized and Most-At-Risk Populations Sufficient Inputs Number of facilities & HRH Service Quality
WHICH SERVICES ARE COVERED?
WHAT PROPORTION OF THE COSTS IS COVERED?
Prioritization & Advocacy Country Targets and Commitments Rights-Based Approaches
Pooled Funding Government Taxes Insurance Contributions Other Sources
Evidence for Interventions Cost Effectiveness Disease Burden
Financial Protection Remove/Reduce User Fees for the Poor Vouchers Reduce Co-Pay for Poor
Expand Capacity Medical Technology Qualified HRH
SOURCE: Adapted from WHO 2010
What Should Drive Allocation and Expenditure Decisions?
HIV Prevalence and Distribution of Health Facilities (Eastern Cape, South Africa)
Consideration of Disease Burden
SOURCE: HPP Analysis, “Mapping HIV variation at sub-national levels in Eastern Cape and KwaZulu-Natal Provinces, South Africa�
Equitable Distribution of Public Health Spending Is Needed
30%
20% 30%
BeneďŹ ts
Need
BeneďŹ ts
Need
Tanzania 2008
10% 20%
0% 10%
0%
40%
Poorest 20%
2nd Poorest
Middle
2nd Richest
Richest
Poorest 20%
2nd Poorest
Middle
2nd Richest
Richest
Kenya 2013
Subsidies
Need
Subsidies
Need
30% 40% 20% 30% 10% 20% 0% 10%
Poorest 20%
2nd Poorest
Middle
2nd Richest
Richest
SOURCE: Ministry of Health, Government of Kenya. 2014. 2013 Kenya Household Health Expenditure and Utilisation Survey 0%
Poorest 20%
2nd Poorest
Middle
2nd Richest
Richest
Long-term Sustainability: A Balance Across Health Needs?
Spending on Ethiopian Health Care, by Function
Curative Care
52% Prevention and Public Health
27%
Health Admin 2% Capital Formation 7% Education / Traning 2% Other 2%
SOURCE: Ethiopia Federal Ministry of Health. April 2014. Ethiopia’s Fifth National Health Accounts 2010/2011. Addis Ababa, Ethiopia
Conclusion
medicine shortage
Only 2 out of 5 health facilities she visits will have the drugs she needs
hard to reach
high fees
1 in 4 women like her don’t seek care when they need it because it’s too expensive
worker shortage
She and ¾ of the mothers in her village will travel ≥ 5 km to a health facility
She has a 50/50 chance of having her baby delivered by a skilled attendant
lack of services
Only 1 out of 5 health facilities she visits will have emergency obstetrics care
poor outcomes
She has a 40% chance of dying from complications of childbirth
Thank You!
www.healthpolicyproject.com The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project's HIV-related activities are supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (previously Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and White Ribbon Alliance for Safe Motherhood (WRA).