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With shifting disease burdens, growing populations, and rising expectations comes a greater focus on value for money. International health funders and agencies want to know how to make the most of money spent by focusing on the highest impact interventions among the most affected populations. Whether through better procurement systems for health commodities, results-based financing, or more detailed assessments of the effective ness of health technology, CGD’s work aims to make health funding go further to save, prolong and improve more lives.
This is a post with Victoria de Menil, program manager for Global Mental Health at The Stanley Center and consultant to CGD.
The theme of this year’s World Mental Health Day (Saturday, October 10th) is “dignity in mental health,” which shines light on the neglect, abuse, and inadequate treatment for the mentally ill in countries at all income levels. Globally, over a billion people are likely to experience a mental disorder in their lifetime, with the majority in low- and middle-income countries (LMIC). Mental illnesses are responsible for 7.4% of global disease burden, and frequently among the top causes of disability including in middle-income countries (Figure 1). These illnesses impose a severe economic burden not only on the individuals suffering from these illnesses but on their families, communities, healthcare systems, and governments.
Figure 1. Leading Causes of Disability in Populous Middle-Income Countries
Notes: (1) Source: IHME GBD Compare, 2013 data. Simplified for visual purposes. For full data, please see: http://ihmeuw.org/3ou6 (2) "Mental health" refers to mental and substance use disorders, neurological disorders, self-harm, and interpersonal violence (3) Countries listed from left to right by total population (4) Cause groupings may differ from linked sources above
A handful of funding agencies have provided monies to mental health research and interventions in LMIC. DFID has committed £13 million towards a multi-site research consortium to improve mental health in primary care and to develop a single country’s (Ghana) mental health care system. The US National Institute for Mental Health and the Wellcome Trust have backed global mental health research initiatives for years. Grand Challenges Canada has committed $32 million to research and service delivery projects across Africa, Asia, Latin America and the Caribbean. The Open Society Foundations have supported essential work monitoring and defending human rights related to mental health care in Eastern Europe and Africa.
Despite this important support, there is still more research than action, and a yawning chasm between what we know and what we do. Less than one percent of international development assistance for health is devoted to promoting mental health or preventing or treating mental and substance-use disorders, and public spending in LMIC themselves is almost undetectable except in the form of psychiatric hospitals.
The evidence base on the cost-effectiveness of mental health interventions, and on the cascade effects of good mental health on other health outcomes, is growing in LMIC. The third edition of the Disease Control Priorities Project (DCP3)—which provides the latest evidence on the efficacy and effectiveness of interventions tackling the world’s largest disease burdens—for the first time dedicates an entire volume on mental, neurological, and substance use disorders, a testimony to the growing (though still inadequate) availability of information on what works.
Building on the DCP3 and other work, a new CGD policy paper explores three big opportunities to scale up cost-effective interventions to improve mental health, based on our own thinking as well as a private group discussion attended by experts in the field.
Our goal was to name three immediate strategies that would help with the financing and implementation of cost-effective mental health care and prevention:
1. Look closely at how mental health interventions fit into health benefits plans
Countries like India, Ethiopia, and South Africa have approached mental health coverage through new mental health policies, but lacked explicit financing to support them. Mechanisms used to prioritize interventions for financing and payment within universal health coverage (UHC) policies, such as national health benefits plans or essential medicines lists, could be a solution to this problem, as long as they are effectively used to budget, procure medicines, and commission/purchase services. Including the treatment of common mental disorders within primary care has been one of the most accessible means of achieving progress. More data is necessary, however, on the extent of mental health coverage within existing national benefits plans, and the degree of budgeting and payment associated with interventions.
2. Build on results-based funding initiatives
Results-based funding between donors and health systems in LMIC may offer an innovative approach to fund mental health programs and to finance providers within health systems, existing as an alternative and complement to other forms of financing such as a traditional development assistance for global health. Investment for mental health could come from a number of new avenues; natural synergies exist between mental health and other non-communicable diseases, as well as maternal and child health.
In fact, the relative silence but growing awareness about mental health within maternal and child health and related areas creates a prime opportunity to step in. For example, a bilateral donor could contribute to the World Bank’s Global Financing Facility in Support of Every Woman Every Child (GFF) with funding earmarked for mental health prevention and treatment. These funds could be distributed within existing RBF packages already funded in the GFF’s target countries. In this way, mental health would be mainstreamed within existing platforms of healthcare, strengthening the overall health system. Another opportunity for scaling up global mental health in the near future could be found in development impact bonds. Attention must be paid to the careful definition of the kinds of outcomes to be incentivized, of course.
3. Cash transfers
The proven effectiveness of cash transfers at overcoming demand-side barriers to accessing healthcare makes them an appealing option, despite some limitations. The opportunities for uptake in global mental health are multiple.
First, a cash transfer program could be designed specifically as a mental health intervention. Based on existing evidence, this would likely be a conditional cash transfer targeting households with specific vulnerabilities towards poor mental health (e.g., low levels of education, high levels of food insecurity). One such vulnerable group is victims of humanitarian disasters. The High Level Panel on Humanitarian Cash Transfers, convened by the British government and chaired by our colleague Owen Barder, concluded that cash transfers are a major opportunity to improve humanitarian aid.
Second, community-based mental health promotion could be incorporated within existing conditional or unconditional cash transfer programs involving health promotion interventions such as health talks. A third opportunity would be to use the targeting platform of existing cash transfer programs to reach vulnerable families and communities and connect them with mental health services. However, these ideas remain to be tested, as at present mental health is mostly absent from discussion of cash transfers.
Building on the momentum of World Mental Health Day and the new DCP3, we’re urging policymakers and global health funders to take these recommendations forward – they are practical, low-cost and potentially high-impact. We’d also like to see the recommendations reflected in upcoming discussions at the World Bank and WHO’s high-level international meeting on global mental health, to be held in April 2016.
One of the things I am proudest of having done in Washington was having the idea as Chief Economist of the World Bank that the Bank should devote its annual World Development Report to making the case for improving both the quantity and quality of global health investment. The 1993 report produced by a team led by Dean Jamison proved more influential than I could have hoped, not least because it drew Bill Gates into the global health arena.
The Report made a strong case that the benefits of the right health investments far exceed the costs. Indeed, I believe the moral and economic case for investments in health care—both prevention and treatment—is as or more compelling than in any other area in the developing world. The dramatic declines in child mortality and increases in life expectancy demonstrate that policy can make an immense difference.
Dean and I chaired a commission, timed to coincide with the 20th anniversary of the initial report, under the aegis of the LANCET. The commission took stock of the remarkable progress made over the last 20 years and emphasized what is possible over the next generation.
The primary conclusion of our commission was that our generation has the opportunity to achieve a “grand convergence” in global health reducing preventable maternal, child, and infectious diseases to universally low levels by 2035. We further concluded that the necessary investments would have benefits that exceeded their costs by a factor of 10. But we cautioned that grand convergence would not just happen. It would require commitments to health system reform and to new domestic and international resources that go well beyond what is in place today.
All of this seems immensely relevant as world leaders gather in New York to agree on a bold new global agenda for sustainable development. The breadth of ambition embodied in the 17 Sustainable Development Goals and the associated 169 targets is truly inspiring and a tribute to the moral energy of many leaders in and out of government.
But there is the risk that with so many priorities, there will be insufficient focus on the most important and achievable objectives. I was therefore excited when the Rockefeller Foundation asked me to work with them to develop a Declaration that a broad spectrum of economists could issue underscoring the importance of global health efforts. The 266 economists who have joined our declaration come from 44 countries and at least as many political and ideological perspectives. But they are united in their belief in the importance of expanding and improving health care globally.
Our Declaration was published in the LANCET and summarized in a full page New York Timesad. I hope the world listens. Millions of lives are at stake.
Note: A version of this blog post originally appeared on larrysummers.com; the original can be read here.
Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption?
This week, emerging economy governments and multinational pharmaceutical executives announced they have agreed to a new way of working together, which should ensure people in those countries get the medicines they need at affordable prices. I’m glad to see this new framework for better priority-setting become a reality. Agreed to in April in Vietnam, it will allow public healthcare payers, the pharma industry and patients benefit from a more transparent process for deciding what drugs are made available to those who rely on strained public health care systems. While I have some questions and reservations about the agreement, at least it begins to address a chronic problem in global public health.
Emerging economies are booming markets for pharmaceutical companies. Roughly one-third of the global pharmaceutical market is expected to be sourced in emerging economies, and the share grows every year. Most of this growth is related to the economies themselves; as populations grow wealthier, more educated and more urban, more healthcare—more services, more medicines—is demanded. And governments are answering the call, declaring their commitment to ambitiously scale up health services and eligible populations.
Yet these higher expectations run into the reality of still-limited public spending on health. Public spending on health generally grows alongside economic growth; historically about 2 percent per year. Because resources are still so scarce, tough decisions have to be made about the allocation of every dollar amongst multiple medicines and devices that may all generate health benefit. The difficulty is to select those that generate the most health, equity, and financial protection for citizens within the available budget.
This has led to fierce competition and high politics. When one company’s vaccine was selected over another’s comparator for public subsidy in the Philippines, the unsuccessful company went straight to President Aquino to complain, triggering legal investigations. When the Government of Colombia introduced new legislation on fast-track registration of biosimilars, similar to legislation included in the US Affordable Care Act, US Vice President Joe Biden (at the request of PhrMA, the US-based pharmaceutical lobbying group) sent a letter to President Santos of Colombia to complain. Aggressive marketing in China led to accusations of bribery. In several Latin American countries, use of the legal system to obtain public reimbursement for medications not approved is common practice.
All of these market and political pressures are normal in a competitive market, but are aggravated by the fact that many emerging economy payers have relied on ad hoc procedures to decide what will be publicly funded. This results in suboptimal outcomes for both government and industry. The multiple pressures run into informal procedures and institutions, resulting in uncertainty on market shares and prices on both sides. This all culminates in the public sensation that people’s health is last on the list of priorities.
In April, public payers—Colombia, Philippines, Vietnam, Thailand—and pharmaceutical executives—including GlaxoSmithKline CEO Andrew Witty and top executives from Janssen and Eli Lilly, among others—met in Hanoi to discuss more systematic ways for public payers to set expectations about what medicines will be funded, reduce uncertainty on implications of decisions to fund or not, and negotiate competing interests in healthcare purchasing. Efforts for more responsible and ethical promotion and marketing of medicines were also discussed. For example, GSK’s recent decision to eliminate incentive payments to sales representatives for the number of prescriptions written was highlighted as a positive development.
Industry in general has long been engaged though not particularly enthusiastic about health technology assessment (HTA) to determine value for money in pharmaceutical spend, in spite of their ubiquitous presence in all OECD countries except the US. Some companies have pushed back against HTA agencies that analyze the cost-effectiveness and budget impact of new medicines and devices and make recommendations for the use of scarce public budgets, arguing these are simply administrative obstacles to market access.
That view may be changing as the possible benefits of fair, scientifically rigorous and transparent rules of the game come into focus. For patients, clearer information on what treatment is available in case of sickness and an entitlement to receive certain services are game-changers. For public payers, more health for money, greater defensibility, and social acceptability of decisions to include or exclude a medication, and fiscal sustainability are key benefits. For pharma, clearer target product profiles, assured volumes or market share when recommendations are made to cover their drugs, and a more level playing field amongst domestic and international competitors will be hugely valuable.
Still, there are questions and disagreements: How fixed are healthcare budgets year-to-year? Should the budget impact analysis of a new product focused on the previous year’s budget be projected forward or focus on a more aspirational budget? Should economic evaluations include non-clinical or health system costs and benefits? Is conducting a health technology assessment to generate a value-based price inconsistent with reference pricing (i.e., asking for a price that a neighboring country received)?
Patients, health ministries and pharma do have one shared goal: they’d like to see a bigger share of public monies to be allocated to health, and for health to be seen as an investment—in people and as an economic sector. Can they agree to play by the same rules of the game?
After a successful replenishment earlier this year, the board of Gavi, the Vaccine Alliance, is thinking through how to maximize the impact of the money it has raised. One hot issue is graduation from Gavi support. Currently, the Alliance uses an income cutoff loosely based on eligibility for IDA — soft loans from the World Bank. Other aid agencies, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, also use World Bank income classifications as an important part of their eligibility and graduation systems.
Within the eligibility and graduation debates, a major touchstone is whether health aid recipients, as they get richer and graduate, are going to pick up essential health services currently funded by aid such as immunizations or antiretrovirals. And, if not, why not and what should donors do about it?
We believe the idea of a ‘financing ditch’ for lower middle income countries (meaning they cannot afford to pay for at least some essential drugs) is over-played. At the same time, donors do have a role in helping recipient countries overcome a ‘priorities ditch’—providing support for more expensive vaccines and global public goods alongside incentives to increase national financing of cost-effective interventions.
The global health partnerships argue, based on Kharas et al, that middle-income countries face a financing ditch as aid declines and tax revenues remain low and that this is a justification for continued aid eligibility. Dercon et al cannot confirm this finding; using more data points, they find no systematic decline in total government resources during early middle-income status and suggest the variation in available revenues between countries at similar income levels likely reflects specific policy choices, not fiscal capacity. Other work on the evolution of health spending as countries grow comes to a similar conclusion: public money for health grows predictably alongside economic growth, but its impact on health depends on policy choices (see our colleagues Victoria Fan and Bill Savedoff’s work on this here).
We agree with Dercon et al that middle-incomes don’t face a financing ditch as a group. Instead, we think there is a middle-income ‘priority ditch’ related to affordability and priority-setting and that this ditch does merit continuation of aid, albeit applying different criteria than those employed to date:
Affordability: price matters for priority. Our recent work on Gavi with Justin Sandefur and Sarah Dykstra shows impact on coverage in currently eligible middle-incomes depends more on the characteristics of the vaccine than the level of country income. Gavi doesn’t add value on relatively inexpensive vaccines but does on the pricier, on-patent but still cost-effective vaccines that countries do not buy on their own. Our work suggests that a vaccine-by-vaccine approach to graduation is the way to go and that some Gavi financing support (or at least lower than market prices) should remain available on some vaccines even after the current income cutoff.
Priority-setting: the policy choices that matter for health. Most middle-income governments lack formal mechanisms to decide what health technologies will be funded with the next available dollar of public money. In the past, decisions on technology adoption have been ad hoc and have generally omitted aid-funded technologies as these were covered by external sources. International guidance and increasing population demands aggravate the problem; new HIV treatment guidelines that double eligible populations, inclusion of high-cost medications on the WHO essential medicines lists, or indeed rapid aid graduations all leave governments struggling to understand what will be the most cost-effective use of their scarce public resources. Our work on priority-setting suggests better approaches are feasible, but support to countries needs to be provided (see here).
Cost-effective for whom: don’t forget global public goods. Some vaccines are only cost effective from a global perspective. For example, a shift to inactivated polio vaccine (IPV) from oral polio vaccine is considered necessary for polio elimination, which would be cost effective and even cost saving from a global viewpoint. But IPV is expensive and not even close to cost effective from a national perspective, where only one or two polio cases might be averted in a given year. A recent study from HITAP in Thailand notes this conundrum, for example. This is why Nancy Birdsall and others have long advocated for aid to focus on these kinds of global public goods.
Better aid incentives. Finally, if the global health partnerships have long provided recurrent funding for cost-effective interventions and suddenly decide to phase out, it is no one’s fault but their own that they didn’t set up the right incentives for governments to finance the most cost-effective expenditure themselves. The partnerships need to structure their aid differently: still achieving price reductions via economies of scale in the purchase of key technologies, but creating mechanisms that reward governments’ own-financing of the most cost-effective services. This matters not only for graduation or sustainability, but also because aid is notoriously volatile and ill-suited to finance key recurrent expenditures like vaccination and antiretrovirals, where any interruption in services puts the worst-off at risk. We’ve been writing about this issue for years; it’s time to finally pay attention (see here, here and here).
What does it all mean for global health partnership boards in the thick of aid eligibility debates? In summary:
Vaccine-by-vaccine not country graduation
Support to more systematic priority-setting for public budgets based on cost-effectiveness
Subsidies to global public goods
Better incentives for countries’ own-financing of most cost-effective services
No one likes the idea of aid to India for antiretrovirals while they finance a space program or aid-funded vaccines to Angola while the country builds Dubai on the South Atlantic with oil revenues. That said, no one likes successful vaccines programs in Nigeria suddenly going unfunded or children left unvaccinated either. Donors at Gavi (and the Global Fund) need to use better tools to ensure aid financing delivers a bigger global health benefit for the dollar — especially amongst richer aid recipients.
India has fallen behind in both health expenditure and health outcomes compared to other lower-middle-income countries. Its burdens of tuberculosis and malaria, and increasingly noncommunicable diseases like diabetes, are among the largest. Infant mortality and child malnutrition rates rival those in sub-Saharan Africa. Public expenditure on health—a mere 1.2 percent of GDP—is less than one-third of South Africa’s and share of out-of-pocket cost is the highest among G-20 countries. On the other hand, India’s thriving medical tourism industry generates revenues of over $70 billion a year—that’s equivalent to one-third of all public expenditure on health in India. It’s clear there’s a high level of inequity in health access and outcomes that must be remedied as a matter of priority.
India’s new draft National Health Policy begins to address some of these problems, outlining a series of much needed reforms. The draft policy appreciates the urgency to achieve universal health coverage—access to quality health care for all without increasing financial burden on individuals and families. It further recognizes the need for higher levels of public expenditure, makes improvements to primary health-care delivery, moves toward a purchaser model for health-care services including both public and private providers, and expands coverage of a national health insurance program targeting the poor.
These are all laudable policy initiatives; however, they don’t go far enough. And more importantly, the policy lacks clear direction in terms of health system design and in coverage of individuals and services.
That’s why, in response to the Ministry of Health’s call for public comment on its plan, we provided recommendations to help strengthen the plan across four key areas: financing and fiscal transfers, payment for performance, priority setting and benefits package, and data and information systems. Our view is that the National Health Policy needs to do four things above others:
Set a target of at least 5 percent of GDP for public expenditure on health.
Move money to the states by providing incentives for performance-based health outcomes.
Design a prioritized, cost-effective, and fiscally sustainable benefits package of health-care services.
Effectively monitor health outcomes by creating a comprehensive database of electronic health records and financial performance.
In our submission (abridged version here), we argue the National Health Policy’s target of 2.5 percent of GDP for public expenditure on health is too low. While it is an increase from current expenditure, it still will not be adequate to address the burden of disease, fill infrastructure and human resource gaps, and reduce out-of-pocket expenditure, especially for the poor. For comparison, middle-income countries such as Mexico and Thailand significantly increased their public expenditure in health to 6.3 and 4.1 percent of GDP, respectively, when they made major pushes toward universal enrollment in government-led insurance programs. Considering the current infrastructure and human resource gaps, India will need to spend at least 5 percent of GDP on health. Universal health coverage will not be achieved on the cheap.
Increasing expenditure is only one piece of the puzzle; spending will also need to be done more effectively. Over the last decade, fiscal transfers through the National Health Mission have been plagued with expenditure inefficiencies. Most states have not been able to utilize funds and are burdened with planning and reporting guidelines imposed by the Central government. This needs to change. States should be given the primary responsibility of implementing the national plan and provided with adequate fiscal space to do so. Greater tax devolution recommended by the 14th Finance Commission is a step in the right direction, as I discussed in an earlier blog. Top-down financing should be replaced with performance-based transfers on the basis of outcomes. The draft policy plan acknowledges this, but fails to explicitly provide how it will move towards greater subnational autonomy and accountability.
The National Health Policy should also establish an independent authority to collect, manage, and analyze health data as its core business. This would be similar to the Unique ID Authority of India (UIDAI), which issues the biometric Aadhaar number. It should be a professionally managed nodal agency that collects data from all levels of government and the private sector, providing data warehousing services for electronic health records and the Health Management Information System, and evaluate performance at State and district levels. India could learn from the experiences of the Mexican Social Security Institute and the National Health Security Office of Thailand, which have been relatively successful in this regard. The goal of creating such an entity would be that data-driven, evidence-based policy and fiscal transfers tied to improved health outcomes would change the health landscape of India in the coming decades.
It’s been nearly 70 years since the Bhore Committee report laid the blueprint for universal health coverage and more than a decade since India’s last national health policy set ambitious targets for achieving health for all. In the end, what is lacking is the political will to make these reforms happen. Will NHP 2015 deliver equitable and quality health care or will it be more of the same? We’ll have to wait and see.
Last September, we released a report on how the Global Fund could get more health for its money. In it, we offered concrete suggestions for improvements in several different value-for-money domains, all with an eye toward maximizing the health impact of every dollar spent.
A lot can change in a year. And during a recent reread of our own report, I was pleasantly surprised by how much the Global Fund has changed for the better, particularly in how it does business. So what’s been done, and what challenges remain?
More Data-Driven Allocation
Under its old system, the Global Fund allocated its funding through a series of proposal rounds. During each round, countries could submit their requests for funding; good proposals would be approved and bad proposals rejected by an expert technical review panel until all available funds were committed.
While well-intentioned, this system was rife with problems. As we wrote in our report, “by failing to provide countries with a clear budget constraint, predictable funding windows, or rewards for efficiency, the Global Fund created strong incentives for countries to maximize their funding requests—often without considering actual need and other funding sources, or assessing their most pressing priorities given scarce resources.” Funding went to countries with the best proposals—not necessarily the countries that had the greatest need or capacity to deliver results. As a result, major differences (up to 5,000-fold!) were seen in per-case spending on HIV across countries, with no obvious justification for the discrepancies.
Fast-forward to today and the Global Fund now deploys an explicit, data-driven allocation formula to split scarce funds across countries on the basis of their disease burdens and ability to fund their own disease programs (the board originally voted to enact a formula-driven allocation approach in 2012; exact allocations for the 2014–2016 window were announced in March). As a result, funding is better aligned with countries’ respective disease burdens, and more predictable funding empowers countries to plan ahead with a clear understanding of the available resource envelope. In a new paper with Victoria Fan and Amanda Glassman, we conclude that this new “methodology is expected, but not guaranteed, to improve the efficiency of Global Fund allocations in comparison to historical practice.”
Still, the fund has experienced some growing pains during its ongoing transition to the new approach. The split of funding across the Global Fund’s three target diseases is based on historical practice rather than objective criteria, and the relatively low allocations for malaria and tuberculosis (32 percent and 18 percent, respectively) remain controversial. Within each disease area, the sources to inform cross-country allocation are inconsistent. In particular, the use of malaria data from 2000 was intended to protect countries where continued funding is required to sustain recent gains; in practice, the fund’s own technical review panel worries that “allocation amounts … may no longer reflect the most strategic investment of resources.” Finally, during the first wave of New Funding Model proposals, confusion about the role of “incentive funding” and competition for its allocation proved a major distraction. But the Global Fund has absolutely taken a step forward toward a strategic, evidence-based approach, and we look forward to watching further refinements over the next few years.
More Results-Based Contracts
In our report and a related paper, we recommended that the Global Fund restructure its contracts to incentivize better results. One year later, we’re pleased to see the fund embrace piloting of results-based contracting mechanisms with open arms, and we’re even more excited to be part of the action.
Here are some highlights: In Rwanda, the Global Fund has signed on to a pilot project where payments are tied to performance against specific HIV outcome indicators. In Mesoamerica (countries of Central America and southern states of Mexico), the fund is supporting a Cash-on-Delivery model to reward countries for progress toward malaria elimination. In Benin, the Global Fund is partnering with the World Bank’s Health Results Innovation Trust Fund to support results-based financing for providers at local health facilities. And many more projects are currently under discussion as the Global Fund explores how results-based financing can become a core component of its overall business model.
One more exciting development: this month, with support from the Bill and Melinda Gates Foundation, and in partnership with both the Global Fund and the Clinton Health Access Initiative, we’re launching a new working group to explore how the Global Fund can best put innovative contracting designs to work across its portfolio—all while striving to maximize the health impact of each dollar and mitigating the attendant risks. The working group will be co-chaired by a high-ranking member of the Global Fund’s secretariat, and we expect that the output will help inform the Fund’s strategy for the next replenishment cycle.
Though the finish line is still far away, the Global Fund deserves kudos for what’s already been done. We’ll continue to check in on movement – but for now we’re happy to see momentum in the right direction.
Last week I participated in the launch of a new Lancet series on universal health coverage (UHC) in Latin America, which aims to showcase and contextualize how the UHC experience has played out to date in the region. And there is a lot to showcase: convergence –as advocated by Larry Summers and colleagues in the Global Health 2035 report – is almost complete in the region, with infant mortality and under-5 mortality similar across many countries with economies of very different sizes. Still, in spite of large increases in public spending, within-country inequalities are still pronounced and out-of-pocket spending remains stubbornly high, even in public health success stories like Brazil. Participants at the event highlighted obstacles to faster progress in these areas, including the fragmentation of risk pools and payment arrangements. Further, citizens’ perceived satisfaction with health systems has remained flat over time, and new pressures associated with growing economies and expectations are increasingly in play.
While the series looks to the past for lessons, I am increasingly worried about the future. The choices made today about what health benefits to cover with public monies will have implications for well-being and spending tomorrow. In a paper released last week, Juan Ignacio Zoloa and I explore what past levels and patterns of aging, risk factors, service utilization, and spending in Brazil, Chile and Mexico might mean for future public spending requirements. Without reforms aimed at expanding policies and programs to prevent disease and enhance the efficiency of health systems, we find that health spending will likely grow considerably in the not-distant future without necessarily improving health access or outcomes. We use long-term fiscal projection techniques employed by the OECD and the Congressional Budget Office to model future spending requirements in the US and Europe, techniques not commonly used in low- and middle-income countries.
The Pan American Health Organization’s Directing Council recently passed a resolution on UHC after weeks of tough debate. The resolution sets out a vision for UHC in the Americas, finally going beyond the “basics” of maternal and child health care which have been the focus of many health systems in the region for decades. But the goals are ambitious: greater access to a “comprehensive, universal package of legally guaranteed services to be progressively expanded in accordance with health needs, system capacities and national context” and elimination of out-of-pocket spending on health, among others. Is the region set for an order of magnitude increase in public spending on health? What reforms need to be undertaken to assure that coverage expansions are high impact on health and fiscally sustainable? What we decide today will play out tomorrow.