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Dr. Shiyan ChaoHealth Care Conference
ArubaJune 1-3, 2015
Health System in Small Island Nations
Challenges and Options
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Outline
1
•Health System in Small Island Countries
2
•Economic Analysis of a Health System
3
•Lessons learned from the Carribbean
4
•Options for improving health care
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The goals of health systems
• The WHO Health System Performance Framework defines the goals of health systems as:– Improving the health of the population they serve– Responsiveness, i.e., responding to people's legitimate expectations
– Fair financing, i.e., providing financial protection against the costs of ill-health.
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Responsiveness
• Defined as a measure of how well the health system responds to the legitimate expectations of the population
• An increasing challenge for all:– How to define quality of care– Necessity for some and luxury for others– Demand and expectation will increased as aging
population and development of medical technology.
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Fairness in Financing
• Every member of society should pay the same share of their disposable income to cover their health costs.
• Universal access and universal coverage –– On paper – In reality
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General Health Financing Functions and Objectives
Revenue collection
• Raise sufficient and sustainable revenues in an
efficient and equitable manner
Pooling• Reduce Risks• Manage these
revenues equitably and efficiently
Purchasing• Provide essential
services which improves health outcomes and provides financial protection and consumer satisfaction
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Revenue Risk PurchasingCollection Pooling
There are Many Ways to Finance a Health SystemP
riva
teP
ub
lic
Taxes
Public Charges/Resource Sales
Mandates
Grants
Loans
PrivateInsurance
Communities
Out-of-Pocket
PublicProviders
PrivateProviders
Service Provision
GovernmentAgency
Social Insurance orSickness Funds
Private Insurance or Community-basedOrganizations
Employers
IndividualsAnd Households
Source: World Bank
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Common Health Financing Models
• National Health Services System• Social Health Insurance• Private Voluntary (mandatory) Health
Insurance • Community-based health Insurance• Director purchase by consumers (user fees)
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Evolution of Health Financing Systems
10
Patient Out-of-Pocket
Social Insur
Gov’t Budget
Gov’t Budget
Social Insur
Patient Out-of-Pocket
Priv. insur
Low Income Countries
Middle Income Countries
High Income Countries
National Health Service
MandatoryHealth Insurance
Private InsuranceSource: Modified from A. Maeda
CommunityFinancing
Patient Out-of-Pocket
Government Budget/MOH
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Total Health Spending as a Share of GDP Relative to Income
Chile
ColombiaCosta Rica
EstoniaKyrgyzstan
Sri LankaThailand
TunisiaViet Nam
05
10
15
Tota
l Health
Spendin
g (
% G
DP
)
100 250 1000 10000 25000GDP per capita (current US$, log scale)
Source: World Development Indicators, WHO 2007Note: GDP per capita in current US$; Log scale
TOTAL HEALTH SPENDING VS INCOME
11
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Government expenditure on health (including external financing) already major part of government expenditure
Source: World Development Indicators (2014)
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Focusing on resources allocation and purchasing
• For whom to buy• What to buy• From whom • How to pay • At what price• Implications to small nations
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Common Vulnerabilities in Small Economy
• Susceptibility to nature disasters and climate change
• Economies vulnerable to exogenous shocks
• Economically less diversified • Often rely on import of basic goods
and supplies
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Challenges in providing health services with in a Small Nation
(less than 2 million population)
• Limited infrastructure for providing all services needed
• It is not economically and technically viable to provide all services needed
• Limited human resources to provide all services needed
• Brain drain in health work force• Limited capacity in administration, management
and research for efficiency gains
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Lessons Learned from the World Bank’s Operations in the Caribbean
• Individual country development vs. regional development
• Collaboration in infrastructure planning• Collaboration in sharing technical expertise• Sharing financing mechanisms (?) • Innovations in sharing and utilization
resources (some examples)
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Priorities in Health Care
• Easy access to quality care• Quality of health care: advanced technology
equipment, skilled health professionals• Equitable coverage• Choices of care• Risk sharing and protection• Sustainability
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Future health care in small island nations will be expensive
• Island populations are increasingly heavier;• NCDs are growing• Populations are aging• Financing resources are not necessarily
predictable• Unmet expectations can be high
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Institute for Health Metrics and Evaluation, Human Development Network, The World Bank. The Global Burden of Disease: Generating Evidence, Guiding Policy –
Latin America and Caribbean Regional Edition. Seattle, WA: IHME, 2013.
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20
1. In 1990 Diarrheal Diseases ranked No. 1 and in 2010, it ranks No. 20.
2. In 1990 Forces of nature ranked No. 174 and in 2010, it ranks No. 2
Top 5 burden of diseases In 20101. Heat diseases2. Forces of Nature3. Violence4. Road injury5. Major depressive
disorder
Changing of Burden of Diseases in Latin America and the Caribbean
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An example of understanding burden of diseases
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Diabetes a particularly severe problem
Source: WDI, 2014
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Treating NCD is Costly
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Two Priorities for Dutch Caribbean Health Systems
• Improve efficiency (quality results with lower costs)
• Contain Costs (managing increased demand with in resources available)
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Options for efficiency improvement
• Managed care model: – controlled and limited choices of service providers– Referral system– Managed competition
• Strategic purchasing– Provider payment methods: per case, DRGs– Defined benefit packages
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On cost control
• Knowing the costs and efficiency• improving prevention efforts• Strengthening primary health care• Developing self-management programs –keeping
patients out of hospitals• Developing new approaches
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Possible Future development
• Tele-medicine, Telementoring, Telesurgery; Telepsychiatry; Telenursing, Telepaediatrics; Home Health
• Medical Tourism: Can your country take a share?
2004 2006 2010 2012 20150
20
40
60
80
100
120
140
The global medical tourism industry is growing by 20-23% annually
(in US$ Billion)
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“Medical Practice in the Caribbean will be marginalized in the medium term as competition now involves e—health solutions overseas such as online pharmacies, therapies …”Professor Davidson Head of School of Public Health and Health Technology in Jamaica
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Key Messages• More resources do not necessarily produce
desired health results• New direction for cost-effective care:
– Patients play a central role in health management– Take advantages of the communication and
technology advancement• Improving sustainability requires do more with
less, seeking for better solutions at lower costs
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Thank [email protected]