As economies grow the challenge is not the resources to scale up health systems, but how the money will be spent, said Ariel Pablos-Mendez, assistant administrator for Global Health at USAID, last week at the World Bank conference Scaling up Health Insurance and Financial Protection in Health in Washington D.C.
PharmAcccess and the Health Insurance Fund were co-organizers of the conference, together with the World Bank and International Finance Corporation, USAID and the International Labour Organization.
“The out-of-pocket expenses in Africa can be cut in half”, predicted Ariel. Universal coverage in his view could be a way to drive health reform by helping countries to build capacity, while the private sector ‘is key in delivering services’. “Most health systems will be mixed”, he said. Universal coverage not just need finance ministers to agree on tax reform or heads of state to bang heads together; half the sector is private, he said. “They play a permanent role in the resolution”, he said.
Julio Frenk, dean of the Harvard School of Public Health and former minister of Health in Mexico, said investments in health care are ‘not just right for ethical, but also economic reasons’. He offered a framework for mixed health systems, distinguishing four essential functions: 1. stewardship, 2. financing, 3. provision of care, and 4. generation of resources.
Stewardship –setting the rules of the game and the strategic direction- and financing are in his view quintessential public functions, which don’t get enough attention in the discussions about universal care. Academic research shows that publicly funded systems perform better, he said. Provision of care and the generation of resources such as human capital and pharmaceuticals are open to private companies.
Two important aspect of stewardship, he said, are whether providers, whether public or private, are delivering the services and are accountable. “Accountability needs to be reinforced on a global level. Governance is an essential part of the equation as it builds trust in government”, the Harvard professor said.
Abdulrahman Sambo, Ag Executive Secretary of the Nigerian Health Insurance Scheme, told about the real challenges in the implementation of health insurance. In Nigeria the first talks about health reform started in 1962, but for the next forty years nothing happened, he told the delegates. The country has a national health insurance, but hasn’t made much progress because the legislation that introduced the National Health Insurance Scheme was ‘seriously defected’. It’s currently being reviewed, he said.
Most countries have many different schemes, noted Kelechi Ohiri, senior adviser of the Ministry of Health of Nigeria. “Scaling-up is difficult given all the vested interests. That is the main challenge when it comes to policy.” When it comes to implementation, Peju Adenusi, managing director Hygeia Community Health Care in Nigeria, said that public-private partnerships should be promoted.
Jacques van der Gaag, director of the Amsterdam Institute for International Development, noted that if you push for equality, choices need to be made. “If you are explicit about the (health) package, you implicitly acknowledge there will be a two-tier system. The rich will be able to buy extra services. That is a realistic view.” The Dutch professor of development economics rejected the tendency to embark on sweeping health system reforms in reaction to ‘pilotitis’, the abundance of pilot programs. “It’s from pockets of insurance you built an integrated system instead of a top down approach imposing a nationwide system. It’s better to knit the different systems together.”