Salman Rawaf The 5 International Conference on Primary ...189.28.128.100/dab/docs/eventos/5aps/apresentacoes/... · Projected Foregone National Income due to Heart Disease, Stroke

Salman Rawaf

The 5th International Conference on Primary Care/Family Health“Primary Care: Now more than ever”, Rio de Janeiro, 24-26 March 2010

[email protected]

WHO Centre

Imperial College London

Ref: 36/2010

mailto:[email protected]

Contents:1. Health Finance

2. Health Systems and Finance

3. Funding Health Systems

4. Effectiveness of Primary Care

5. Setting Objectives and Targets

6. Now, more than ever

© WHO Centre, London

WHO Collaborating Centre, London

WHO Centre, Imperial College London

Health System Goals

Better Health

Responsiveness to person’s needs

Financial Protection against health care costs


Universal

Coverage

Liberal

Medicine

Resilience of

Insurances

The Choice

of Doctor

Different Priorities


French patients consume twice

more drugs than their European

counterparts

The Choice

of Doctor

© WHO Centre, IC London

Funding Health Systems


Health Finance


Methods of Raising, Pooling and Allocating

Capital (Developmental) and Revenue

(Recurrent, Operational) Funds in equitable

and efficient ways to meet the population’s

health needs

Financing Health Systems

General Taxation (Sweden, UK, Italy, Spain, Canada, Australia)

Social Insurance (France, Germany, Austria, Belgium)

Private Insurance (USA)

Out-of-Pocket

Mixture© WHO Centre, London

Health Systems

NHS (Sweden, UK, Canada, Australia)

Social Insurance (France, Germany)

Free Market (USA)

Mixture of the three

+ Medicare & Medicaid (elderly, disabled + Poor)


Health Systems

National Health Service (Sweden, UK, Canada, Australia)

Social Insurance (France, Germany)

Free Market (USA)

Mixed

PHC Accountability Gov. Role

PHC-

led

Public Strong (if not devolved)

Weak

(Improving)

Public/

Insurance

Weak-

Strong

Very

Weak

Insurance/

shareholders

Very

Weak

variable variable variable


General

Taxation

Soc Insurance Private

Insurance

OOP/Co-pay

Sweden 84 16

Australia 70 - 8 16

Canada 69 1 11 17

UK 82 10 4 6 Prescriptions

France 3 74 13 10

Germany 6 69 7 13

USA Medicare & Medicaid

(Elderly, Disabled, Poor)55 ?

Public % Private %

Source of Health System Finance: Global 05/6

© WHO Centre, London Source: S Rawaf ICL

General

Taxation

Soc Insurance Private

Insurance

OOP/Co-pay

Sweden 84 16

Australia 70 - 8 16

Canada 69 1 11 17

UK 82 10 4 6 Prescriptions

France 3 74 13 10

Germany 6 69 7 13

USA Medicare & Medicaid

(Elderly, Disabled, Poor)55 ?

Public % Private %

Source of Health System Finance: Global 05/6

100% access

1/6 of pop. with no insurance

© WHO Centre, London Source: S Rawaf ICL

Health System Funding: General

WHO Centre, IC London S Rawaf 2009

LIC MIC HICPrivate OOP

Private Pooled

Government

© WHO Collaborating Centre, London Source: Eurostat OECD

Professor S Rawaf

100(GDP)

289.3(GDP)

Health Spending in the ECC (Six Countries)

1965 = 100

4.9%

10.2 %

1965 2006


Australia: June 2009 Redesigning our health system to meet emerging challenges

1. Embed prevention and early intervention

2 „Next generation‟ of Medicare

“The Government will be responsible for bringing together

state-funded primary health care services and medical

services under Medicare to create a comprehensive primary

health care platform. This will include a focus on promoting

good health, early intervention and better managing chronic

disease.

3. ..........


Example:

Malaysia


40914589

5022

6068

70267593

10,442

11,92611,045

9,65810,606

13,393

10,602

8,494

60265494

5447472143774122

0

2000

4000

6000

8000

10000

12000

14000

16000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

RM

billio

n

Public Sector Private Sector

Public/Private Mix: Malaysia


Growth of OOP Spending: Malaysia

© WHO Centre, IC London Source: Rawaf, 2009

Market Regulations/ seamless services between primary & secondary services Professor S Rawaf

• Public Health & PHC

• Secondary + Tertiary Care

Funding4 Commissioning/ Contracting Provision

State Funding and Delivery * Regulations, Cross-cutting Issues, HRD, etc

H Insurance:

Employers

-Employers’

Contributions

(family-based)

- Gov Contribution

H.I.: Self Emply:

- Gov HI Sold \

(x% Cost)

-Identify % core

Subsidy

H.I.: General-Funded

-Unemployed

-Disadvantaged

- Elderly/Retired

--Refugees

- Disabled etc

Collect

ion

H Insurance (Funding) Agency/Authority

Public Hospitals

University Hoapitals

Private Hospitals

NGOs

OverseasProviders

Commissioning1 Acute Services

Commissioning2 Mental Health

CommissioningCommunity Ser

Other than PH & PHC

Contingency 3Fund

Malaysia 2009


Effectiveness of Primary care


Evidence shows:

The importance of a robust system of primary

care for health economies

High-quality health systems and healthy

populations require strong and effective primary

care services.

B Starfield, 1994, 2005

Weak PHC Countries

Strong PHC Countries

1970 1980 1990 2000

500

0

Countries shifted the focus of their health system from specialized hospital-based to PHC

1000

OECD Countries: Potential Years Life Lost (PYLL)

Source: B Starfield

© WHO Collaborating Centre, London B Starfield, 2005

Health Professional Supply & Child Survival

Source: Chen et al, Lancet 2004; 364:1984-90.

Densi

ty (

work

ers

per

1000)

Child mortality (under 5) per 1000 live births3 5 9 5

0

100 250

25

15

10

5.0

2.5

1

*186 countries


? Organisation

© WHO Centre, IC London Source: Commonwealth Fund, 2008

Australia Canada Germany NZ UK

Overall Ranking 2007 3.5 5 2 3.5 1

Quality Care 4 6 2.5 2.5 1

Right Care 5 6 2.5 2.5 2

Safe Care 4 6 3 4 2

Coordinated care 3 6 4 2 1

Pt Centered Care 3 6 2 1 4

Access 3 5 1 2 4

Efficiency 4 5 3 2 1

Equity 2 5 4 3 1

LH Productive Life 1 3 2 4.5 4.5

Health Expenditure P

Per Capita, 2004 $

2,876 3,165 3,005 2,083 2,546

High Performing Systems: Quality of Care

© WHO Collaborating Centre, London

0

20

40

60

80

100

120

140

160

180

1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9

England: Deaths due to Vascular Diseases


Setting Objectives & Targets


Public Health

InterventionsPersonal

Care


National Institute for HealthPrevent Risk & Disease (PH + PC)

Reduce Risk & Maintain Low Risk

Reduce Admission (%)

Reduce Mortality (%)

Improve Quality of Life

WHO Centre, Imperial College London C Schoen et al, 2009

Primary care Doctors Role & Payment 2009


The UK

Vascular Checks


A single, universal, integrated

check for all aged 40 - 74

• Measure risk of

cardiovascular disease,

diabetes and chronic

kidney disease

• Set out how to reduce

risk/maintain low risk

• Offer tailored package of

prevention


UK: Vascular Check


• Offer 3m vascular checks a year

• Cost about £250m before savings

And each year will prevent at least:

- 9,500 heart attacks and strokes

- 2,000 deaths

- 4,000 people developing diabetes

Estimates

The UK Program will:


Now, More than Ever


Universal Coverage1

Universal Coverage reforms

• "Progressive" financing for health for all

– based on pre-payment and pooling mechanisms to:

• Ensure availability of services, and

• Eliminate financial barriers to access

• But that is not enough:

– mobilize beyond the health sector to social protection schemes– give visibility and voice to the invisible and voiceless– reach the unreached



Non-Communicable Diseases 2

The difficult adaptation to new challenges

2010

CVA

CHD

Cancer



National Institute for Health

Worldwide: The 10 leading causes of Death2004


National Institute for Health

Annual Deaths due to Tobacco Million

Projected Foregone National Income due to Heart Disease, Stroke and Diabetes

Brazil 2.7 49.2

China 18.3 557.7

India 8.7 236.6

Pakistan 1.2 30.7

Russian Federation 11.1 303.2

US$ Billion

Source: Preventing Chronic Disease: A Vital Investment, WHO 2005

200510 years

accumulated



Technological Advances3

© WHO Centre, Imperial College London

Professor S Rawaf

Family Physician

Effective Gate-Keeping Function

Only Relevant referral

No Delay

Patient Choice

Follow-up

Cost-Effectiveness

Patient Satisfaction

Seamless Service

Hospital Reception

Hospital specialist

No Medication



Social Protection4

Every year, globally, 150 million people suffer financial

catastrophe and 100 million people are pushed into poverty

due to health spending

- 30,000 60,000 90,000

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (1,000)

impoverishment

catastrophic

First do no harm!


High Costs = People Search for

Cheaper OPTIONS


-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

% growth government health spending

% r

eduction U

5M

R 1

990-2

015

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

0% 3% 5% 8% 10% 13% 15%

5% economic growth

& 2.5% female education growth

& 2.5% roads growth

& 2.5% water & sanitary growth

& 2.5% growth in all

Investments are Needed

Across Many Sectors to Achieve MDGs

© WHO Centre, IC London Source: WB, GS

And Finally .......

Thank You

Documents

Salman Rawaf The 5 International Conference on Primary ...189.28.128.100/dab/docs/eventos/5aps/apresentacoes/... · Projected Foregone National Income due to Heart Disease, Stroke