Access and Equity Presentation 2024 PDF

ACCESS AND EQUITY Dr. Nitya Kumar vha.org.au  Learning outcomes You will be able to: ▪ List and explain the principle enablers and obstacles to communities accessing health care services ▪ Define and explain with examples the concept of...

ACCESS AND EQUITY Dr. Nitya Kumar vha.org.au  Learning outcomes You will be able to: ▪ List and explain the principle enablers and obstacles to communities accessing health care services ▪ Define and explain with examples the concept of Equity as it applies to individuals and communities who need to access and utilise health services ▪ Discuss progress and remaining gaps towards achieving Universal Health Coverage in the health system in which the students are training ▪ Describe and discuss the main mechanisms for financing health services and their advantages and disadvantages in respect to equity and access to health services 2 Definition and dimensions of access to health services The timely use of personal health services to achieve the best possible health outcomes. It encompasses: ✓Availability: is healthcare physically present? ✓Accessibility: can people reach healthcare services? ✓Affordability: are services financially accessible? ✓Acceptability: are services socially and culturally acceptable? ✓Quality: are services effective, safe, and patient-centred? Universal Health Coverage: “all people have access to services and do not suffer financial hardship paying for them” (World Health Report, 2010) 3  Individual: Level of education Previous experience with health system Levels Enablers and Barriers Autonomy Social capital for access to health services Household: Household income Social capital Religious beliefs Community: Cultural beliefs Religious beliefs Health System : Distance to health facility Cost of health care Waiting time at health facility Attitude of health workers Availability of essential medicines and supplies  Consequences of limited access Health Disparities and inequities Unequal access contributing to preventable diseases, early mortality, and poor health outcomes Higher disease burdens in disadvantaged groups Economic Impacts Financial burden on household Reduced productivity due to untreated illness Social Impacts Widening of social and health disparities Marginalisation of vulnerable populations 2. Equity, access and outcomes  Definitions – inequality and inequity Inequality in health Inequity in health ▪ Any measurable aspect of health ▪ Differences in health between that varies across individuals or groups which are unjust and according to socially relevant could be avoided by reasonable means groupings ▪ inequality in determinants of health, and in access to resources ▪ No moral judgement applied to needed to improve and maintain those differences health or achieve health outcomes. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO Arcaya et al. (2015) Inequalities in health, definitions, European review of social determinants of health and the concepts and theories. Global Health Action 8 27106 health divide. Lancet 2012; 380: 1011􀀁 29. 7  Equity in Health It’s not about everybody getting the ▪Equity: absence of avoidable differences same thing, it’s about in benefits available to groups of people, everybody getting whether those groups are defined socially, what they need in economically, demographically, or order to improve the geographically. quality of their situation. (Silvia Parker) ▪Health equity: creating equal opportunities for health, and bringing health differentials down to lowest level possible. Disparities in access to maternal health services in low-income countries v high-income countries Yaya & Ghose (2019) https://pmc.ncbi.nlm.ni h.gov/articles/PMC6608 688/ 9 https://www.gapminder.org/fw/world-health- chart/  Lifespan 80 74 70 There are no countries here. On this high income, there are no 60 countries with life expectancy below 74. 50 Income $500 $5 000 $50 000 Sources: After 1950: UN World Pop. Prosp. 2012. Before 1950: hundreds of sources combined by Gapminder. www.gapminder.org/tea ch Free teaching ma te rial for a fact-ba sed worldv iew Version: 1  Lifespan 80 There’s no country here. On this low income, there’s no country with life 70 expectancy above 64. 64 60 50 Income $500 $5 000 $50 000 Sources: After 1950: UN World Pop. Prosp. 2012. Before 1950: hundreds of sources combined by Gapminder. www.gapminder.org/tea ch Free teaching ma te rial for a fact-ba sed worldv iew Version: 1 13 Improving Access to Health Services: Strategies Interventions Policy interventions: Community-based approaches: ▪ (UHC) as a key framework ▪ Utilising community health ▪ Health financing reforms workers to bridge gaps Health system strengthening: ▪ Public health campaigns and mobile health units ▪ Increasing healthcare workforce Addressing social barriers: ▪ Strengthening primary healthcare services and referral systems ▪ Cultural competency training for healthcare professionals ▪ Decentralising health services to improve rural and underserved areas ▪ Legal and policy reforms to remove discrimination and support vulnerable groups  Universal Health Coverage https://www.youtube.com/watch?v=LWEjDhV5tio  Universal health coverage (UHC) This definition of UHC embodies the following three elements 1. Equity in access to health services - those who need the services should get them, not only those who can pay for them; 2. Range and quality of services good enough to improve the health of those receiving services; 3. Financial-risk protection - ensuring that the cost of using care does not put people at risk of financial hardship.  The 3 dimensions of UHC and their trade-offs 1. Population - Who is covered ? Difficult to access populations expensive to reach If a country values equity, it will invest here 2. Services - Which ones are covered? Stick to a package of essential services? Or invest in including other (non-essential and often expensive) services? 3. Cost - What proportion of costs are covered? Current pooled funds refers to the funding invested by the state (through taxes) Cost-sharing and fees refers to what service users pay. Can the state cover the additional costs? On which of the 3 dimensions should the state spend more money – trade-offs between policy objectives?  How can we measure UHC? ▪ Proportion of a population that can access essential quality health services (SDG 3.8.1) is one of the indicators of UHC ▪ Proportion of the population that spends a large amount of household income on health (SDG 3.8.2) is another indicator  What is needed to achieve UHC? For a country to achieve UHC, several factors must be in place, including: 1. A strong, efficient, well-run health system that meets priority health needs through people-centred integrated care 2. Affordability – a system for financing health services so people do not suffer financial hardship when using them. 3. Access to essential medicines and technologies to diagnose and treat medical problems. 4. A sufficient capacity of well-trained, motivated health workers to provide the services to meet patients’ needs based on the best available evidence. 5. Actions to address social determinants of health such as education, living conditions and household income which affect people’s health and their access to services. Policy level barriers to achieving UHC 1. The availability of resources: – No country, no matter how rich, has been able to ensure that everyone has immediate access to every technology and intervention that may improve their health or prolong their lives. 2. Overreliance on direct payments: – These include over-the-counter payments for medicines and fees for consultations and procedures – results in catastrophic costs. 3. Inefficient use of resources – 20–40% of health resources are wasted. Reducing waste would greatly improve the ability of health systems to provide quality services and improve health. Health system financing mechanisms https://vimeo.com/87885079  Revenue – means of getting funding Revenue collection is concerned with the sources of funding for health care, types of payment, and agents that collect these revenues. All funds for health care, excluding donor contributions, are collected in some way from the general population or certain subgroups. Collection mechanisms include: 1. Taxation - direct and indirect 2. Employee / employer contributions – social health insurance 3. Private health insurance 4. Out-of-pocket payments Catastrophic expenditure Out-of-pocket spending for health care (often emergency surgery) that exceeds household’s ability to pay, causing it to drop below poverty line. This is the rationale for ‘pooling risk’ – where the state or an insurance company carries the risk  Health system funding models 1. Beveridge - Provided and financed by the government through tax payments. - healthcare facilities can be owned by the Government, may also be privately model owned with Government funding, - majority of health staff in this model composed of government employees. - Low costs per capita and benefits generally standardised across the country - Health as a human right, is a central tenant of this model, with universal health coverage and equal access to care guaranteed by the government. - Criticism: the tendency toward long waiting lists with everyone guaranteed access to health services, often leading to over-utilisation and the risk of increasing costs  Health system funding models 2. Bismarck - Uses an insurance system usually financed jointly by employers and employees through payroll deduction. Model - It is a health insurance plan that in principle must include all citizens, and is non-profit in nature, although in practice tends to be available only to the working population with the allocation of resources to those who contribute financially, so as such does not provide universal health coverage. - higher accessibility, lower waiting times and often higher quality and more consumer-oriented healthcare, thought to be as a result of competition between healthcare providers - criticism of the Bismarck model is how to provide care for those who are unable to work or can't afford contributions, including ageing populations and the imbalance between retirees and employees.  Health system funding models 3. National Health - Uses private-sector providers, but payment comes from a Insurance Model government-run insurance programme that every citizen pays into. - provides universal insurance, no financial motive to deny claims and no profit, - cheaper and simpler administratively than For-Profit or Private Insurance Models 4. Out-of- pocket/private model - Healthcare is driven by income - the rich get medical care; the poor stay sick or die.  Health system financing mechanisms 1. Taxation - direct and indirect 2. Social health insurance - Employee / employer contributions 3. Private health insurance 4. Out-of-pocket payments 1. Taxation Direct tax: Usually funds collected through taxation are allocated to Health annually through cabinet decisions and/or by ministries of Finance – direct (eg income) tax more effective if large numbers in formal employment. Indirect tax: taxes on products that are harmful to health have the dual benefit of improving the health of the population through reduced consumption while raising more funds 2. Social Health Insurance compulsory universal coverage under a public social security system financed by employee + employer contributions Everyone above an income threshold must pay a contribution based on income or ability to pay Contributions to the ‘social insurance fund’ kept separate from government tax revenue Tax and Social insurance are ‘progressive’ – need and not ability to pay determines access to services  3. Private Health Insurance Contract between an individual and Principle an insurance company ‘Risk-sharing’: the assumption that Individual pays an annual some people will not require treatment fee (a premium) during the year. Their payments subsidise those whose treatment will Insurance company cost more than the level of premiums undertakes to pay for care they paid if s/he falls ill a) Risk assessors (actuaries) Problem assess risk that s/he will fall ill ‘Risk-selection’: insurance companies b) Company determines premium may choose not to insure level based on risk assessment (discriminate against) those at higher risk  4. Out of pocket payments (OOP) Out of pocket payments: the individuals’ direct payments to Solutions? healthcare providers at the time of service use ✓ Exemption of people with low or no income Catastrophic expenditure: Out-of- ✓ implementation of a maximum pocket spending for health care, that amount of OOP expenditure for exceeds household’s ability to pay, medicines in a year. causing it to drop below poverty line  Healthcare Financing: Bahrain Health services are financed by the national Health Insurance Fund ( National Health Insurance Law (NHIL), Law No. 23 of 2018 ) Mandatory medical insurance for all. Premiums are paid by o Govt, for citizens. o Employers, for expatriate employees o Visitors, licensed worker without an employer, unemployed expats pay their own premiums All citizens and residents can access primary health care centers  Activity: Health system financing & UHC ▪ Log on to the WHO Compare the following indicators for Bahrain financing database: & Afghanistan https://www.who.int/teams Health spending: /health-systems- -General Govt. Health Expenditure governance-and- -Out of Pocket Payments financing/health- financing/hfpm- background-indicators UHC: - Service coverage index  Questions? Discussion Forum on VLE E-mail: [email protected] THANK YOU 36