Inke Mathauer

Bio: Inke Mathauer is an academic researcher from World Health Organization. The author has contributed to research in topics: Health policy & Social determinants of health. The author has an hindex of 14, co-authored 30 publications receiving 968 citations. Previous affiliations of Inke Mathauer include University of London.

Universal Coverage of Health Services: Tailoring Its implementation/Couverture Universelle Des Services De Sante : Adaptation De Sa Mise En oeuvre/Cobertura Universal De Los Servicios De Salud: Adaptacion De Su Aplicacion

Abstract: Introduction Out-of-pocket payments create financial barriers that prevent millions of people each year from seeking and receiving needed health services (1,2) In addition, many of those who do seek and pay for health services are confronted with financial catastrophe and impoverishment (3-5) People who do not use health services at all, of who suffer financial catastrophe are the extreme Many others might forego only some services, or suffer less severe financial consequences imposed by user charges, but people everywhere, at all income levels, seek protection from the financial risks associated with ill health A question facing all countries is how their health financing systems can achieve or maintain universal coverage of health services Recognizing this, in 2005 the Member States of WHO adopted a resolution encouraging countries to develop health financing systems aimed at providing universal coverage (6) This was defined as securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost Thus, universal coverage incorporates two complementary dimensions in addition to financial risk protection: the extent of population coverage (eg who is covered) and the extent of health service coverage (eg what is covered) In some countries it will take many years to achieve universal coverage according to the above-mentioned dimensions This paper addresses a number of key questions that countries will need to address and considers how the responses can be tailored to the specific country context In addition, it highlights the critical need to pay attention to the role of institutional arrangements and organizations in implementing universal coverage Shifting to prepayment A first important observation is that many of the world's 13 billion people on very low incomes still do not have access to effective and affordable drugs, surgeries and other interventions because of weaknesses in the health financing system (1) We investigated 116 recent household expenditure surveys from 89 countries, which allowed calculations of the consequences of paying for health services by those who do use them Up to 13% of households face financial catastrophe in any given year because of the charges associated with using health services and up to 6% are pushed below the poverty line Extrapolating the results globally suggests that around 44 million households suffer severe financial hardship and 25 million are pushed into poverty each year simply because they need to use, and pay for, health services (7) Households are considered to suffer financial catastrophe if they spend more than 40% of their disposable income--the income remaining after meeting basic food expenditure--on health services They are often forced to reduce expenditure on other essential items such as housing, clothing and the education of children to pay for health services Households are considered impoverished if health expenses push them below the poverty line Inability to access health services, catastrophic expenditure and impoverishment are strongly associated with the extent to which countries rely on out-of-pocket payments as a means of financing their health systems These payments generally take the form of fees for services (levied by public and/ or private sector providers), co-payments where insurance does not cover the full cost of care, or direct expenditure for self-treatment often for pharmaceuticals A major challenge, therefore, to the achievement of universal coverage is finding ways to more away from out-of-pocket payments towards some form of prepayment Solutions are complex, and countries' economic, social and political contexts differ, moderating the nature and speed of development of prepayment mechanisms (8) Policy norms in health financing Health financing policy, however, cannot afford to focus just on how to raise revenues …

Universal coverage of health services: tailoring its implementation

Abstract: In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services - where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.

Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

Abstract: Objective This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries It also explores design and implementation issues and the related challenges countries face Methods A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization's Regional Library of Medicine and Google Findings Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts All countries have set expenditure ceilings In general, systems were piloted before being implemented The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting Conclusion Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management

Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand.

Abstract: This paper contributes to analysing and understanding the demand for (social) health insurance of informal sector workers in Kenya by assessing their perceptions and knowledge of and concerns regarding health insurance and the Kenyan National Hospital Insurance Fund (NHIF). It serves to explore how informal sector workers could be integrated into the NHIF. To collect data, focus group discussions were held with organized groups of informal sector workers of different types across the country, backed up by a self-administered questionnaire completed by heads of NHIF area branch offices. It was found that the most critical barrier to NHIF enrollment is the lack of knowledge of informal sector workers about the NHIF, its enrollment option and procedures for informal sector workers. Inability to pay is a critical factor for some, but people were, in principle, interested in health insurance, and thus willing to pay for it. In sum, the mix of demand-side determinants for enrolling in the NHIF is not as complex as expected. This is good news, as these demand-side determinants can be addressed with a well-designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates.

Health financing reform in Kenya- assessing the social health insurance proposal

Abstract: Kenya has had a history of health financing policy changes since its independence in 1963. Recently, significant preparatory work was done on a new Social Health Insurance Law that, if accepted, would lead to universal health coverage in Kenya after a transition period. Questions of economic feasibility and political acceptability continue to be discussed, with stakeholders voicing concerns on design features of the new proposal submitted to the Kenyan parliament in 2004. For economic, social, political and organisational reasons a transition period will be necessary, which is likely to last more than a decade. However, important objectives such as access to health care and avoiding impoverishment due to direct health care payments should be recognised from the start so that steady progress towards effective universal coverage can be planned and achieved.

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

Abstract: While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

Health Systems Financing and the Path to Universal Coverage

Abstract: Donor commitments to health have increased more than fourfold since the Millennium Declaration was signed in September 2000, reaching more than US$ 20 billion in 2008.1 Despite this, progress towards some of the health Millennium Development Goals (MDGs) has been disappointing in many settings.2 The simple act of raising more international funds cannot, by itself, achieve the Goals if the health system is too weak to support the rapid scale-up of service coverage.3 Where there are insufficient health workers and health facilities, or where people can’t obtain health care because they cannot afford to pay, supporting actions are needed. Domestic health financing systems must be robust enough to attain and sustain increased coverage. Financing for universal coverage is based on two interlinked foundations. The first is to ensure that financial barriers do not prevent people from using the services they need – prevention, promotion, treatment and rehabilitation. The second is to ensure that they do not suffer financial hardship because they have to pay for these services.4 Health services cost money and someone has to pay. Even with the recent increase in external funds for health in low-income countries, these countries still have to find almost 75% of their health funding in domestic sources. The way that countries raise those funds is critical. Direct payments required when people obtain care (e.g. user charges) prevent many people from seeking care in the first place, and may result in financial catastrophe, even impoverishment, for many.5 Improving universal coverage requires systems that raise the bulk of funds through forms of prepayment (e.g. taxes and/or insurance), and then pool these funds to spread the financial risk of illness across the population. They require health financing systems with inbuilt incentives to ensure that these funds are used efficiently and equitably. The World Health Organization’s next world health report will be on health financing and will argue that almost every country, rich and poor, can improve service coverage or financial risk protection by addressing one or more of the core tasks of a financing system – raising sufficient funds, pooling these funds to spread financial risks and spending wisely. The Bulletin of the World Health Organization has been running a series of news stories since December 2009, showing how health financing systems affect people’s lives. Reports have been published in the following order from Spain,6 China,7 Thailand,8 the Republic of Korea,9 Switzerland,10 Nigeria11 and, in this issue, the United States of America.12 In addition, some of the issues that policy-makers inevitably face as they develop their health financing systems are highlighted in perspectives published this month. In terms of raising more funds, Fryatt & Mills13 outline the main achievements of the high-level Taskforce on Innovative International Financing for Health Systems. They claim that it has helped maintain momentum for increased international financial support for health in low-income countries at a time of the financial crisis. In response, McCoy & Brikci14 argue that the Taskforce report was disappointing. It gave only lukewarm support to a financial transactions levy, an option targeting the banking sector, while supporting consumer taxes affecting the poorer population groups. The focus on innovative financing could also backfire by encouraging countries to renege on their commitments to provide official development assistance – in fact only a few of them have kept their international promises to date. Yates15 focuses on how funds for health are raised and makes a case for abolishing user fees, starting with services for women and children. On the other hand, Jowett & Danielyan16 claim that the debate about user-charges is not so straightforward. For example, Armenia has developed an official fee schedule for health services as a way of countering unofficial or under-the-table payments. Finally, Leatherman & Dunford17 report that microfinance increasingly provides relatively poor people, often women, with income-earning opportunities and suggests that it might also help people to access health services where they must pay for them. Many countries are very close to universal coverage and others are making good progress. The Bulletin’s articles on this topic raise fundamental questions that must be considered when thinking about how best to develop and adapt national health financing systems for universal coverage.

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries.

Abstract: Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.