This presentation is made on the first ever Universal Health Coverage (UHC) Day 12.12.14 celebration in Nepal by Nepal Health Economics Association (NHEA).

1. Universal Health Coverage Day,
12 December 2014
Let’s Get Started

2. Presentation by
Deepak Kumar Karki, General Secretary, NHEA
Devi Prasai, Vice-President, NEHA
Shiva Raj Adhikari, Member, NHEA

3. For Today
Universal Health Coverage (UHC):
Progress So Far and Way Forward in Nepal

4. What is Universal Health Coverage?
Universal health coverage means
that every person, everywhere,
has access to quality health care
without suffering financial hardship.

5. Why Now? (1)
Health is a human right and a
cornerstone of sustainable
development and global
security
Universal health coverage
changes the way that health
care is financed and delivered –
so it is more equitable and
more effective

6. Why Now? (2)
Because Nobody should go Bankrupt when They Get Sick
Because UHC is Attainable
Because UHC can Stop the World’s Biggest Killers
Because Health Transforms Communities, Economics and
Nations
Because Health is a Right, Not a Privilege

7. Background of UHC
Human dignity
•Recognizes that inequalities
in access to treatment or
gross disparities in health
outcomes creates indignity
Human security
•Recognizes that forced
payments for
healthcare are a source
of insecurity
Solidarity
• Implies that the burden
of funding healthcare
be distributed fairly,
and that the better-off
should assist the worst-off.

8. Taking the Note
• United Nations GA/67 Session Global Health and Foreign Policy
Adopted on 12 December 2014
• World Health Report 2010, entitled “Health systems financing:
the path to universal coverage”
• Social Protection Floor Initiative endorsed by the United Nations
Chief Executives Board for Coordination in April 2009
• Mexico City Political Declaration on Universal Health Coverage,
adopted on 2 April 2012
• Bangkok Statement on Universal Health Coverage, adopted at the
Prince Mahidol Award Conference on 28 January 2012
• Tunis Declaration on Value for Money, Sustainability and
Accountability in the Health Sector, adopted on 5 July 2012

9. Why UHC?
As a means to achieve
better health or poverty
reduction or sustainable
development outcomes
Equity in outcomes or
opportunities or risk
protection are important as
ends in themselves

11. Requirements in measuring UHC
1. Measures of ends
• Indicators that assess the extent of UHC attainment across
countries in comparable and consistent manner to inform
policy and research
• To assess relative performance
• To assess improvements
• To help identify critical factors
2. Measures of means
• Indicators that assess critical factors that enable or prevent
attainment of UHC
• E.g. Public financing, risk-pooling, etc.

12. Definition
“Every citizen will have access to and utilization of
highest attainable standard of services without
financial difficulties”. WHO
Every citizen will have
access to and
utilization
Population
Coverage
highest attainable
standard of services
Service coverage
with quality
Without
financial
difficulty
Financial
coverage

13. Service coverage

14. What services do we include?
• Cost effective.
• Addresses the major burden of disease
• Serves the larger population.
• Improve health of poor and disadvantaged
• Ensuring the right of the citizen
• Availability of resource (fiscal space)

15. Including service may reduce the population coverage
of other services
90%90%90%
54%54%54%54%54%
Ensure the additional resource for added services
30%30%30%30%30%30%30%30%30%
3 services
5 services
9 services
Options 3
Options 2
Options 3

16. Adding service increases level of
financial protection
Out of Pocket
expenditure 74%
Hotchkiss at al, 1998
9 services
Out of Pocket
expenditure 62.5%
Prasai et al, 2006
Adding
CB IMCI,
10 services
Out of Pocket
expenditure 60 %
Shrestha et al,2011
Adding
4 more
services
13
1996
1999/2000
2006-08

17. Adding service
Before NHSP Included services in
NHSP 1
Included services in NHSP 2
Reproductive Health -Medical safe abortion
-UP(Prevention and M.
Child Health CB IMCI -CB Nutrition,
- CB newborn care
CD
NCD
disease control
-CB mental health Program
-Health promotion NCD
-Oral
-Eye Care
-Rehabilitation of Disabled
-Environmental Health
Curative Care Outpatient care

18. National Free Care Policy
a step towards UHC
Evolution Reforms
December 15, 2006 Declared targeted free care at district hospitals and
PHCC (inpatients and emergency care)
October 8, 2007 Declared the abolishing user fees at HPs/ SHPs
Nationwide and made service free to all
January 16, 2008- Implemented the policy of free to all health post and
sub health post
November 16, 2008 Expanded universal free care to PHCC level
January 15, 2009 -Declared free outpatient care at DHs to the targeted
population nationwide,
-Declared 40 free essential drugs free to all at district
hospitals nation wide
-Declared all essential drugs free to targeted groups
nationwide

19. Service coverage under universal and targeted
free are
Service covered All people Targeted groups
Outpatient care up to
district hospital
X X
Inpatient care X
Emergency care X
Support services
• Routine laboratory
test
X
•General X Rays X
Referral service X

20. Measuring UHC through three dimensions
Extend to
non-covered
Reduce cost
sharing &
Population: who is covered?
fees
Direct costs: proportion
of the costs covered
Current pooled funds
WHR, 2010

21. Reforms is Needed in the Health
System
• The implementation plan for universal coverage must
improve all dimensions of the health system.
• These dimensions include
• the ‘breadth’ (number of people protected),
• the ‘height’ (proportion of costs covered), and
• the ‘depth’ (range of services and benefits covered),
• as well as those additional factors that influence quality and
safe services that contribute to improving health status

22. Breadth: population covered
• Coverage breadth: 100%
population coverage:
• All population groups and their
families need to be covered:
• Formal sector employees,
informal sector workers, self-employed,
unemployed, students,
pensioners, rural/urban,
rich/poor, dalit/nondalit …

23. Population Coverage: service consultation
and self-reported adequacy of services
Percentage of service consultation
Percentage of self reported
adequacy of health services

24. Access to Health Services

25. Breadth
(increasing the number of people protected by the
health systems)
• Addressing physical, financial and access limitations.
• Strategies may include:
• Increasing the staffing levels of primary health care (PHC)
facilities, changing opening times of clinics;
• Encouraging and rewarding collective and integrated group
practices;
• Changing policies to encourage task-shifting or task-sharing,
building more clinics;
• Expanding mobile outreach services and home-based care,
subsidizing transport to and from health facilities and
expanding patient transport services.

26. Coverage Depth
• Coverage depth:
• Defined package of service
based on market
segmentation
• Available resources:
• What can the country
afford?
• Health service priorities
• Preferences for specific
services

27. Service Coverage:
Using Tanahashi Model

28. Service coverage: some examples

29. Depth – increasing the range of services and
benefits covered by the system
• Service packages for various levels of care, aligned to local
burden of disease, define access and related services.
• Changes in facility staffing to allow a greater range of
services to be provided at designated PHC service delivery
points, task-shifting or task sharing
• To reduce the time costs of highly skilled professionals
(including shifting nursing tasks from professional nurses
to nursing assistants and from doctors to nurses and other
assistants) and spending more on health services than in
the past.
• Decide necessary on the scope of the essential service
package and on initiating periodic reviews of the package

30. Coverage Height
• The emphasis is on prepaid
and pooled contributions to
the health financing system
• Tax -based financing
• Social health insurance
• Mix of tax - based financing
• Mixes of community,
Cooperative and enterprise-based
health insurance,
other private health
insurance

31. Financial protection
Protecting people
from:
• financial
consequences of
illness and death
• financial
consequences
associated with the
use of medical care
No financial
hardship associated
with ill health
• Curative,
preventive,
promotive and
rehabilitative
services
What is the role of
direct out-of-pocket
(OOP) payments?
• Inequitable and
inefficient !

32. % Change in THE between 2000 and 2012
Health expenditure has grown
faster than income on a per capita
basis .
Health expenditure as a percentage of
GDP in 2012 was 5.5 % in Nepal, an
increase of 0.4 percentage points from
2000.

33. Change in share of public expenditure and OOP
between 2000 and 2012
The share of out-of-pocket has fallen
by 19.6 percentage points since
2000.
The share of public expenditure has
increased by 14.9 percentage points
since 2000.

34. Share of External Resources
• External resources
accounted for 10.1 %
of total health
expenditure in Nepal.
• There is negligible
change in share of
external resources
between 2005 and
2012.

35. Financial Coverage
Total Health Expenditure by Financing Sources
17.3
19.8 23.7
18.5 20.8 21
61.5
60.5
55.6
65.7
62.5
60.5
21.1
19.7 20.8 15.8
16.7 18.5
80
60
40
20
0
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
In Percent
Fiscal years
General government Private sector Rest of the World

36. Financial Coverage
5.0
5.2
THE as % of GDP
5.1
5.7
5.6
5.3
4.9
5.3
5.3
5.8
5.6
5.4
5.2
5.0
4.8
4.6
4.4
2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Per cent
Fiscal Years

37. Out of Pocket Payment and
Payment for Medicines in Nepal
61.5 60.5
55.6
65.7
62.5
60.5
OOP as % THE
34.5
32.6
26.0
30.8
27.7 26.0
Medicine as % of THE
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

38. Per Capita GDP and THE
294 323 350 390
464 465
Per capita GDP in USD
Per capita THE in USD
16.8 18 18.6 19.3
24.9 24.8
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

39. Government Expenditure and
Medicine Payment
1.5 1.5
1.6
1.5
2.0
2.1
Public health Expenditure as % GDP
34.5 32.6
26.0
30.8
Medicine as % of THE
27.7 26.0
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

40. Impact of OOP
Financial shocks
or welfare loss

41. Assessment of FP in Health
• Financial protection is generally assessed:
• based on out-of-pocket (OOP) spending on medical care
• and such payments are related to a threshold (e.g., poverty line)
• Two methods:
1) Catastrophic spending
 Medical outlays that exceed a certain threshold (z) of household
income or resources (incl. non-subsistence expenditure).
2) Impoverishment
 Medical outlays that are sufficient enough to dip a non-income
poor household into poverty

42. Catastrophic and Impoverishing Impact
OOP impacts have increased, such as the catastrophic impact (or financial shocks) have
increased 6 percent to 11 percent at 10 percent threshold from 1995/96 to 2003/04.
Similarly, improvising impact has increased 2.2 to 2.5 percentage point same study period.

43. Financial Coverage
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Catastrophic incidences based on total consumption
5 10 15 25
Share of Ability to pay (incidence)
Thresholds Levels
NLSS I NLSS II NLSS III

44. 50%
40%
30%
20%
10%
0%
Financial Coverage
Catastrophic Incidences based on
Non-Food Consumption
5 10 15 25 40
Share of Non Food Consumption
Threshold levels
NLSS I NLSS II NLSS III

45. OOP Impact on Poverty

46. Financial incidence analysis
The results from two Nepal living Standards Survey data 1995/96 and 2003/04 suggests
better off pay more for health care not only in absolute terms but also relative to
income. But poor don’t utilize health care as per their needs.

47. Health Care Utilization
Consumpti
on quintile
Consulted Not
consult
ed
Tota
Kabiraj/Baid
ya
Tradition
al
Doctors Paramedic l
Poorest 8.1 42.4 1.1 5.4 43.1 100
second 16.6 40.1 0.2 2.9 40.3 100
Third 20.6 42.4 0.2 2.5 34.4 100
Fourth 30.9 34.3 1.2 4.3 29.3 100
Richest 45.7 25.2 1.4 1 26.8 100
• It does not mean that poor are comparatively healthier than the rich people.
• In fact, they have greater incidence of disease but their inability to meet basic
requirement such as food availability makes them compelled to overlook health
problems.

48. Who gets benefit from health care?
0.3664
0.4932
0.2943
0.4642
0.2987
0.0281
Gini Hospital care Non hospital care
1995/96 2003/04
All concentration indices for hospital care and non-hospital care are significantly positive,
indicating pro-rich bias. But the concentration indices for non-hospital care are much closer
to zero, indicating proportionality than those for hospital care.

49. Who gets benefit from health care?....
0.1268
Kakwani Index
1995/96 2003/04
-0.0677 -0.1350
-0.4070
Hospital care Non hospital care
The Kakwani indices are significantly negative in 2003/04 indicating that public health
care is income inequality reducing, despite the fact that it typically not pro-poor. Non-hospital
care has greater power to reduce income inequality than hospital care.

50. System of health financing

51. Free Health Care
Facility Charge
SHP Khodpe, Baitadi Rs 10
Health Post Siddheshwore
Baitadi
Rs 10
PHC Patan, Baitadi Rs 5
PHC Manglabare, Morang Rs 10
PHC Manthali Rammechhap Rs 20
SHP Okhreni Ramechap Rs 10
HP Those Ramechap Rs.10
Thada PHC Argakhachi RS 10

52. Challenges
• How to implement policies that mitigate the financial
hardships still faced by the poor in using health services
• How to identify the poor for premium exemption
• How to increase fiscal space to cover those in the
informal sector
• Exploring the major determinants of the lack of financial
protection, including the detailed reasons for lack of
financial protection
• Assessing equity dimensions to financial risk protection
- by age, sex, location, SES, etc.

53. Health budget competing with other
social services budget (growth rate)
Education Health Drinking Water Local Development
2002/03 2003/04 2004/05 2005/06 2006/07 2007/08
The health sector has benefited in terms of receiving more resources due to
fluctuations in drinking water and local development services

54. Height – increasing the proportion of costs covered
by pre-financing (more funding and less waste)
• These may include a range of financing options:
• Social health protection coverage through national health services,
• Social health insurance, community-based insurance and mandated private health insurance
• Improvement efficiency of health system
• Improving procurement and administrative efficiencies,
• Creating synergistic effects For example, using the inputs of other sectors and departments that
impact on health determinants, such as water and sanitation, education and women and children
These may include a range of financing options:
• Social health protection coverage through national health services,
• Social health insurance, community-based insurance and mandated private health insurance
• Improvement efficiency of health system
• Improving procurement and administrative efficiencies,
• Creating synergistic effects For example, using the inputs of other sectors and departments that
impact on health determinants, such as water and sanitation, education and women and children.

55. Financing mechanisms
• It represents an integrated approach, respects existing coverage and
financing arrangements, and can be adjusted to the specific social
and economic context of each country
• Broadening sources of financing and better use of resources
• Money matters to the health care system, but it does not guarantee
efficient, equitable, and effective health care services. Health care
financing has the power to reform health care delivery and provide
incentives to providers to deliver efficient and effective health care
• Specific strategies to engage non-state providers to UHC

56. Engineering of UHC
Covering all services but not population
Financial coverage but not
population and services
Population coverage but not
Services and financial

57. Strategies
Categorize services into priority classes. Relevant criteria include
those related to cost-effectiveness, priority to the worse off, and
financial risk protection.
First expand coverage for high-priority services to everyone. This
includes eliminating out-of-pocket payments while increasing
mandatory, progressive prepayment with pooling of funds.
While doing so, ensure that disadvantaged groups are not left
behind. These will often include low-income groups and rural
populations

58. Glocalization: Designing of UHC
• Global localization = Glocalization
• Global agenda and designing and implementing based
on local condition (indigenous system) = UHC
Glocalization
• If Glocalization; UHC for Nepalese citizen
• If not Glocalization; Nepalese citizen for UHC
• Then, expected outcomes: blame to be given to
Nepalese citizen and cost of UHC on the head of
Nepalese citizen

59. UHC is a Long Journey……
Thank You !!!