for Sustainable Development

Reinhard Busse, Prof. Dr. med. MPH Department of Health Care University of Technology (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies Instead of a formal introduction ME AND UNIVERSAL HEALTH CARE – THE STORY SO FAR

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Seoul: where it all began 20 years ago

Represented:

China Costa Rica Czech Republic Egypt Indonesia Japan Morocco Republic of Korea South Africa Thailand Vietnam

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Discussed: SHI only for up.-middle/ high income?

No! Germany and Japan started with compulsory SHI when they were poor/ low-income countries (in today‘s terms)

Seoul, 14 January 2016 Universal Health Care for Sustainable Development 10 years ago: how to visualize coverage?

Seoul, 14 January 2016 Universal Health Care for Sustainable Development The first Coverage Cube was born …

Seoul, 14 January 2016 Universal Health Care for Sustainable Development … picked up by WHO only a year later …

Seoul, 14 January 2016 Universal Health Care for Sustainable Development … and again in 2010 …

Seoul, 14 January 2016 Universal Health Care for Sustainable Development … copied and modified elsewhere

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Looking at the data UNIVERSAL HEALTH CARE – HAVE WE SEEN PROGRESS SINCE 2000?

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Global health expenditure in 2000 …

600 $PPP 7.7% of GDP

Private (16% … and in 2012 VHI , 23% 56% Public OOP ) 1170 $PPP (23% tax , 33% SHI ) 8.6% of GDP

Private (15% VHI , 22% 58% Public OOP ) (23% tax , 34% SHI )

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Low-income country health expenditure in 2000 …

32 $PPP 2.9% of GDP

Private (1% VHI , … and in 2012 53% OOP ) 83 $PPP 38% Public 5.1% of GDP (37% tax , 1% SHI )

Private (1% VHI , 47% OOP ) 39% Public (38% tax , 1% SHI )

Seoul, 14 January 2016 Universal Health Care for Sustainable Development By 2012, budgetary spending on health had increased by 1% of GDP (39% of +2.2% of GDP)

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Lower middle income country health expenditure in 2000 … 108 $PPP 3.9% of GDP

Private (2% VHI , … and in 2012 59% OOP ) 235 $PPP 34% Public 4.1% of GDP (29% tax , 5% SHI ) Private (2% VHI , 55% OOP ) 36% Public (31% tax , 5% SHI )

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Upper middle income country health expenditure in 2000 … 263 $PPP 5.3% of GDP

Private (8% … and in 2012 VHI , 43% 47% Public OOP ) 766 $PPP (27% tax , 19% SHI ) 6.0% of GDP

Private (7% VHI , 32% 56% Public OOP ) (29% tax , 27% SHI )

Seoul, 14 January 2016 Universal Health Care for Sustainable Development High income country expenditure in 2000 …

2390 $PPP 9.6% of GDP

Private (16% … and in 2012 VHI , 19% 60% Public OOP ) (22% tax , 4520 $PPP 38% SHI ) 11.6% of GDP

Private (15% VHI , 19% 61% Public OOP ) (21% tax , 40% SHI )

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Using the Cube to look at a few issues in detail BUT WAS OUR VIEW COMPLETE?

Seoul, 14 January 2016 Universal Health Care for Sustainable Development 1st issue: Who is (not) covered?

Seoul, 14 January 2016 Universal Health Care for Sustainable Development VHI

SHI

Not covered

“Coverage” by access to tax-financed provision

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Putting this pre-UHC into the cube …

V H I SHI Tax

RICHEST POOREST 1. WHO (sorted by income)?

Seoul, 14 January 2016 Universal Health Care for Sustainable Development ‰ need to extend coverage to “missing middle” by (1) extending tax-financed coverage or …

Seoul, 14 January 2016 Universal Health Care for Sustainable Development (2) extending the SHI system

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Looking at a few examples

Thailand without a missing middle (but rich partly excluded)

Vietnam as an example of missing middle

Ghana as an example of an immature pro-rich system

Seoul, 14 January 2016 Universal Health Care for Sustainable Development 2nd issue: What is (not) covered?

…

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Putting this issue into the cube …

Most would agree that “essential services” should be covered; but what is essential? Many agree that this will differ from one country to the next; but how do

UHC

dominant in countries?

Scope to learn from economic evaluation which services to include: (1) monetary effects > costs (“dominant”) (2) costs per life year saved are < GDP/ capita ( ‰ WHO-CHOICE)

Seoul, 14 January 2016 Universal Health Care for Sustainable Development Examples from a recent systematic review

Seoul, 14 January 2016 Universal Health Care for Sustainable Development A wider issue: coverage only step 1 to 3 of access Need (by socio-economic status, ethnicity/ migration status etc.)

Coverage

Realised Unmet access/ Unmet need effective need coverage x Quality = Outcomes ‰ Performance of Seoul, 14 January 2016 Universal Health Care for Sustainable Development Are the efforts worth it? THE CONTRIBUTION OF UNIVERSAL HEALTH CARE TO SUSTAINABLE DEVELOPMENT

Seoul, 14 January 2016 Universal Health Care for Sustainable Development For individuals: poverty ↓↓↓ in informal sector

Seoul, 14 January 2016 Universal Health Care for Sustainable Development For society: economic growth ↑↑↑

Seoul, 14 January 2016 Universal Health Care for Sustainable Development UHC may only be one of 17 SDGs, but it has a central role for overall goal achievement! In spite of noticable progress in the past, many countries (esp. lower middle income) can speed-up. All should monitor progress closely.

Seoul, 14 January 2016 Universal Health Care for Sustainable Development