Phusit PrakongsaiKanitta Bundhamcharoen
Kanjana TisayatikomViroj Tangcharoensathien
International Health Policy Program (IHPP)
Presentation to IHPP Journal Club IHPP meeting room, Ministry of Public Health, Thailand
January 8, 2009
Regional case studiesFinancing health promotion in South-East Asia:
Does it match with current and future challenges?
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Outline of presentation
1. Background and objectives of the case study2. Burden of non-communicable diseases (NCD)
and risk factors 3. Financing health care and health promotion 4. Innovative financing for health promotion 5. Stakeholder views on financing health
promotion 6. Conclusions and policy recommendations
Background (1)Increasing burden of NCD and risk factors
Source: WHO (2006) Preventing chronic diseases: a vital investment
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Background (2)
• Evidence indicates very low investment in health promotion and disease prevention in South-East Asia region
• The 59th session of WHO-SEAR regional committee meeting in Dhaka, 2006– Request member states to adopt alternative,
innovative and sustainable sources of financing HP activities,
– Request RD to facilitate the establishment of innovative financing mechanisms
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Innovative financing HP in five selected countries (1)
• India: – The National Rural Health Mission is funded by
10% of tobacco tax of the central government– MOH plans to get at least 1-2% tax from tobacco to
finance tobacco control-related activities
• Nepal: – introduction of ‘cigarette tax’ in 1993 – one pisa
per stick of cigarettes (then increased to two pisa)– 75% of the fund to BPK Cancer hospital, and 25%
to other similar establishments
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Innovative financing HP in five selected countries (2)
• Sri Lanka:– has comprehensive tobacco and alcohol legislation with
taxation policy,– Establishment of the National Tobacco and Alcohol
authority funded by the central revenue
• Thailand:– Has comprehensive tobacco and alcohol legislation – Establishment of Thai Health Promotion Foundation,
funded by 2% of tobacco and alcohol excised taxes
• Indonesia:– No comprehensive tobacco or alcohol legislation– No national health accounts
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Objectives
• To conduct case studies on the innovative and sustainable financing mechanisms using information from national health accounts and other sources of information:
1. Reviewed the profile of non-communicable disease burden,
2. Examined current policy concerns among key
stakeholders on health promotion and financing health promotion,
3. Assessed current trend of financing sources of health promotion (public vs private) and spending profile,
4. Assessed the structure, function, and achievements of innovative financing HP.
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Methods• Literature reviews on
– Burden of disease, or extensive epidemiological situations of NCD
– Revenues generated for alcohol and tobacco, and laws related to taxation and tax rates
• Reviewed existing National Health Accounts (NHAs) about financing health care in general and HP in particular
• Conducted self-administered questionnaire survey to achieve key stakeholder views on innovative financing HP
• Reviewed innovative financing health promotion and country without such innovation, in-depth interviews of key stakeholders will be conducted.
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Research findings from this study
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DALY Profile of 11 member states of SEAR and the world
0 10 20 30 40 50 60 70 80 90 100
Sri Lanka
DPR Korea
Thailand
Indonesia
Maldives
WORLD
SEA region
India
Bangladesh
Myanmar
Nepal
Bhutan
Timor-Leste
Non-communicable Communicable Injury
Source: The World Health Report 2004
Country background indicators in five selected countries, HDI rank in 2007
Indicators Thailand Sri Lanka
Indonesia India Nepal
HDI rank 78 99 107 128 142
Population in 2015 (million)
66.8 20 251.6 1,302.5 32.8
GDP per capita US$ 2,750 1,196 1,302 736 272
Pop living below $1 a day (%)
<2 5.6 7.5 34.3 24.1
Health spending per capita, PPPUS$
293 163 118 91 71
Birth attended by skilled health personnel (%)
99 96 72 43 11
Physicians per 100,000 pop
37 55 13 60 21
Prevalence of selected risk factors in five selected countries
Risk factors Gender India Indonesia Nepal Sri Lanka Thailand
Alcohol consumption (litre per cap)
0.29 0.09 0.19 0.28 5.59
Smoking (%) Male 29.4 69.0 31.4 38.2 40.2
Female 2.5 3.0 2.0 2.4
Mean blood pressure (mmHg)
Male 124 123 124 123 119
Female 122 123 121 122 117
Physical inactivity (%)
Male 9.3 24.4 6.7 7.3 6.8
Female 15.2 17.8 9.7 13.8 11.8
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Total health expenditure as percentage of GDP 2000-2004
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Total health expenditure by financing sources in five selected countries in 2004
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Financing health promotion and innovative financing
• The Health Tax Fund of Nepal raised by earmarked tax of tobacco and alcohol consumption, is managed the BP Koirala Memorial Cancer Hospital,– Approximately 65-70% for Bhaktapur Cancer hospital,– the rest for National Health education, Bir Hospital,
Nepal Cancer Relief Society, etc.
• Revenue of Thai Health Promotion Foundation (THPF) collected from 2% earmarked additional tax from tobacco and alcohol consumption – In 2005, total expenditure was approximately 58 million
USD,– The mission is to empower civic society, raise social
awareness on major health risk behavior, promote well being of the citizens.
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The distribution of HP programs funded by THPF in 2005
The distribution of HP programs supported by ThaiHealth in 2005
34%
17%16%
16%
12%
5%
Tobacco & alcohol consumption control, road traffic injuries, etc.
Health promotion is specific population
Community capacity strengthening
Knowledge management in health promotion
Drug addiction, sexual behaviour, mental health, nutritional and environmental projects
Health promotion by health care infrastructure
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30.46
25.3622.47
19.47 18.94
0
5
10
15
20
25
30
35
1991 1996 2001 2004 2006
Trend of prevalence (percent) of regular smokers among population aged more than 11 years from 1991 to 2006
Sources: Analyses from the Health and Welfare Survey, 1991-2006
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nd Correlation between prevalence of cigarette smoking and percent of
excised tax on tobacco and number of cigarette consumption from 1991 to 2006
Tax increase interventions and tobacco control
In Thailand
30 .525 .4
22 .5 19 .5 18 .9
55
79
0
10
20
30
40
50
60
70
80
90
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
year
pe
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0
500
1,000
1,500
2,000
2,500
3,000
Nu
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(m
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prevalence of cigarette smoking
percent of excised tax on tobacco
Number of cigarette consumption in million packs
Stakeholder views on financing health promotion (1)
Characteristics Indonesia Nepal Sri Lanka Thailand Total
No. of respondents
37 27 34 117 232
Male: female 62:38 84:16 74:26 77:21 75:25
Average age of respondents
NA 55.9 55.6 50.2
Professional background
Medical professionals
30% 28% 37% 18% 25%
Health related administrators
- 25% 17% 50% 32%
Public health 38% 16% 30% 25% 27%
Others 32% 31% 16% 7% 16%
Perception on financing health care and health promotion
Indonesia Nepal Sri Lanka
Thailand Total
Sufficiency of health care finance
Inadequate 86.5 93.8 78.3 82.1 83.6
Adequate 8.1 3.1 19.6 16.2 13.8
Don’t know 5.4 3.1 2.2 1.7 2.6
Government priority on HP
High priority 8.1 18.8 15.2 24.8 19.4
Moderate 16.2 50.0 54.3 59.0 50.0
Low priority 75.7 31.3 30.4 14.5 29.7
Spending on health promotion in relation to burden from NCD
Indonesia Nepal Sri Lanka
Thailand Total
Sufficiency of financing HP in relation to NCD
Abundant 0 0 0 0.9 0.4
Sufficient 13.5 0 4.3 15.4 10.8
Moderate 5.4 25.0 32.6 22.2 22.0
Insufficient 62.2 65.6 52.2 52.1 55.6
Severely insufficient
18.9 9.4 4.3 8.5 9.5
Don’t know 0 0 6.5 0.9 1.7
No. of respondent 37 32 46 117 232
How much should governments spend on health promotion?
Indonesia Nepal Sri Lanka
Thailand Total
Double of current level of spending
24.3 50.0 43.5 26.5 32.8
Triple 43.2 21.9 21.7 16.2 22.4
Quadruple 13.5 9.4 4.3 4.3 6.5
More than quadruple
18.9 3.1 6.5 9.4 9.5
Don’t know 0 9.4 19.6 11.1 10.8
missing 0 6.3 4.3 32.5 18.1
No. of respondent
37 32 46 117 232
Desirability of innovative financing for HPPotential sources of financing HP
Indonesia Nepal Sri Lanka
Thailand Overall
Earmarked tax from alcohol
3.86 4.53 3.95 4.51 4.30
Earmarked tax from tobacco
4.11 4.52 3.88 4.41 4.27
International donor
3.78 3.91 3.88 2.49 3.17
Domestic donor 3.89 3.13 3.27 2.73 3.08
Earmarked tax from VAT
3.22 2.96 2.48 2.95 2.90
General tax 2.95 3.30 2.65 2.78 2.85
Earmarked tax from SHI
2.68 3.75 NA 3.73 2.83
Earmarked from gasoline
3.03 2.50 1.75 2.66 2.52
Reallocation from other sectors
1.97 2.48 1.95 2.25 2.18
Feasibility of innovative financing for HPPotential
sources of financing HP
Indonesia Nepal Sri Lanka
Thailand Overall
Earmarked tax from alcohol
3.92 4.43 3.95 4.21 4.14
Earmarked tax from tobacco
4.08 4.34 3.93 4.21 4.15
International donor
3.81 3.67 3.77 2.09 2.92
Domestic donor 3.89 2.75 2.90 2.40 2.79
Earmarked tax from VAT
3.22 3.04 2.83 2.39 2.70
General tax 2.86 3.12 2.76 2.59 2.74
Earmarked tax from SHI
2.68 3.07 NA 3.07 2.40
Earmarked from gasoline
3.14 2.62 1.88 2.12 2.30
Reallocation from other sectors
2.03 2.11 1.83 1.62 1.79
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Opinions on key barriers to introducing innovative financing for HP
• Lacking of vision and commitment to improving population health among politicians and policy makers,
• Limitations of financial and human resources for HP and disease prevention,
• Bureaucratic system and poor management of the government,
• Poverty and lack of community participation,
• Lacking of knowledge and inadequate information on the magnitude of NCD and its impact on public health.
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Conclusions
• Current level and profile of spending on health promotion and disease prevention does not match huge disease burden from NCD,
• Among these five countries, Thailand paves advanced step towards innovative financing health promotion, – Nepal had an opportunity to reorient towards primary
prevention rather than focusing on hospital-based cancer treatment,
– Sri Lanka, the introduction of tobacco and alcohol tax could be a potential source,
– The introduction of social health insurance in Indonesia provides an opportunity to ensure that disease prevention and health promotion services are included in the benefit package of SHI.
• Disease Control Priorities in Developing Countries 2006 (second ed) – DCP2
• Comprehensive literature reviews on cost-effectiveness interventions ใน 4 four groups:
– Infectious disease, reproductive health, and under-nutrition
– Non-communicable disease and injury,
– Risk factors,– Consequences of disease and injury
• It also provides recommendations on health system strengthening, and effective management for high priorities of disease prevention and health promotion. http://www.dcp2.org/pubs/
DCP
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Policy recommendations from the case study
• Mobilize more resources through increased public investment for health promotion,
• explore potential feasibility to establish innovative financing for health promotion through introducing earmarked tax from tobacco and alcohol,
• Ensure that public health insurance schemes cover health promotion in their benefit packages,
• Well prepare good evidence when the window of opportunity is opened,
• Increase value of money, namely efficiency gained through existing spending on health promotion and reorient programs towards primary prevention focus.
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Policy recommendations from the regional consultation in Jakarta (1)
Member states
• Need to mobilize more resources through increased public investment for health promotion, with a need to reorient towards primary prevention and promotion focus.
• Have to explore potential feasibility to establish innovative financing for health promotion through:– general revenue;– introducing dedicated tax from tobacco and alcohol;– ensuring health insurance funds to cover the prevention
and health promotion in their benefit packages.
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Policy recommendations from the regional consultation in Jakarta (2)
WHO
• WHO, in collaboration with regional institutions, needs to develop a guide/methodology for collecting and analysis of information on financing HP,
• Should widely disseminate the experience of use of the dedicated tax and alternative financing,
• Provide technical support for capacity building for policy and program development.
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Thank you for your kind attention