DESK REVIEWS | 02.02.04.01. Are there any planned changes to the financing strategies or financing mechanisms to fund the health system?

DESK REVIEW | 02.02.04.01. Are there any planned changes to the financing strategies or financing mechanisms to fund the health system?

Brazil is undergoing a socio-political and economic transition. Since 2018, Brazil is under a new government, which has been adopting austerity measures that are likely to affect the SUS. Some estimates show impacts that might be linked to these measures on healthcare of the population, such as: increased infant mortality, worsened regional disparity regarding infant mortality, increased inequalities regarding the Family Health Strategy (FHS) coverage and among mothers who regularly attend antenatal care centres. Changes in FHS coverage are likely to affect smaller municipalities disproportionately, given the stronger dependence of small municipalities on primary healthcare (Castro et al., 2019). So far, no comprehensive plan for the future exists. While the Constitutional Amendment Proposal Number 241 (PEC 241), approved in 2016, limits public expenditures and consequently affects the SUS, the Ministry of Health has strengthened the Primary Healthcare by expanding the number of working hours and the quantity of primary healthcare units. However, it is still too early to assess possible changes in the financing of the health system.

References:

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public. https://www.abrasco.org.br/site/wp-content/uploads/2019/07/PIIS0140673619312437.pdf

India has a semi-federal governance structure. Public responsibilities are shared either by the Union or the States or both. Health is a State subject in India. Thus, Union and State strategies for health might align, differ, or co-adapt. Government spending on health is mainly based on budget allocations as part of the annually announced Union (Central) budget as well as state budget allocations and central transfers to states.

A scheme launched by the Government of India in 2018 is the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY), which is part of the Ayushman Bharat programme. This scheme is designed to have a defined benefit cover of Rs. 5 lakh per family per year (National Health Portal, 2019). Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private impanelled hospitals across the country (National Health Portal, 2019). It is an entitlement-based scheme with entitlement decided based on deprivation criteria in the Socio-Economic Caste Census database (National Health Portal, 2019).

The Ayushman Bharat flagship programme brings together initiatives of the National Health Insurance (PMJAY) and the Health and Wellness Centres (HWCs) (National Health Portal, 2019). The programme is based on tax-based financing and thus, critically depends on the Centre’s allocations to the programme.

References:

National Health Portal. (2019). Ayushman Bharat Yojana. Government of India. Available from: https://www.nhp.gov.in/ayushman-bharat-yojana_pg

Yes. The Ministry of Health in Indonesia pursues a five-step Strategic Plan (2015-2019). The key aspects on the agenda are the ‘revitalization of community health centres (puskesmas)’, continuation of care, and ‘specific solutions for specific health problems’. Planned changes to the financing strategy have only been outlined for community health centres. The Ministry of Health declared the aim to ‘increase […] the budget for facilities and support for puskesmas’ but it did not explicitly outline how this will be approached (Claramita et al., 2017, p.9). The Ministry of Health further states the aim to reduce ‘household burden [due] to finance health services’ from 37 per cent to 10 per cent (Ministry of Health Republic of Indonesia, 2015a, p.45).

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The new initiative for the country is to move towards universal coverage (funded by the World Bank). A pilot has been rolled out in 4 counties (described under 2.01.03.01). It is planned to roll out cover for all households by 2022 to guarantee access to equitable, affordable, and high-quality health and related services for all citizens. Other financing strategies by the government in addition to the UHC are through taxation and health insurance contributions (to cover basic essential services). The contributions are discussed in 1.04.01 under social protection schemes. General tax revenue is 30% of value added tax which is charged at 16%. Import and excise duty each account for 10% of the total revenue while corporate tax for companies ranges between 20% and 37.5% depending on the company’s existence. A proportion of the taxes are allocated to health care in Kenya (Chuma & Okungu, 2011). These financing mechanisms translate direct household payments into prepayment so that OOP are kept at a minimum (Njuguna & Pepela, 2019).

References:

Chuma, J., & Okungu, V. (2011). Viewing the Kenyan health system through an equity lens: implications for universal coverage. International Journal for Equity in Health, 10(1), 22. https://doi.org/10.1186/1475-9276-10-22

Njuguna, D., & Pepela, W. (2019). A Case for Increasing Public Investments in Health: Raising Public Commitments to Kenya’s Health Sector. Nairobi, Kenya. https://sparc.africa/wp-content/uploads/2020/01/Kenya-Health-Financing-Policy-Brief.pdf

One of the main campaign promises was to end the fragmented nature of the health system and work towards a single universal health system. As of January 2020, the government eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies with the objective of generating a sole, centralised health system with integrated public financing and delivery, while reducing private participation. To this end, President Lopez Obrador (referred to by his initials, AMLO) created the Institute of Health and Wellbeing, INSABI (Instituto de Salud para el Bienestar), but to date (July 2020), no real changes have been implemented. A first study of the proposed reform notes large challenges, many that should have been overseen before implementation, and summarises their findings in five lessons: First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government’s restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization” (Reich, 2020).

References:

Reich, M. R. (2020). Restructuring Health Reform, Mexican Style. Health Systems & Reform, 6(1), e1763114. https://doi.org/10.1080/23288604.2020.1763114