Financing and delivery models for quality health care for low-income groups

7/25/2019 Financing and delivery models for quality health care for low-income groups

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Financing and delivery models for quality health carefor low-income groups

ADB Meeting on Harnessing and Aligning the Private Sector for UHC, 26 -27 Jan 2016


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WHY IS IT THAT WE ARE ALWAYS

TALKING ABOUT THE PROBLEM OF

DRUG DISTRIBUTION, WHEN THERE IS

VIRTUALLY NO PLACE INAFRICA

WHERE ONE CANNOT GET A COLD

BEER OR A COLDCOCA-COLA.

JOEP LANGE

1

Founder Joep Lange


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Origins in Academic Medical Center, University of Amsterdam 1995 mother child transmissions studies in Africa

2000 PharmAccess foundation: treatment in Africa

2002 initiated HIV treatment programs: Heineken, Shell,

Celtel, Diageo, Unilever, Coca-Cola,

2005 HIV/AIDS program for army forces in Tanzania (PEPFAR program

still running in 2014)

2006 Health Insurance Fund ( 150 mio USD public fund)

2007 research: Amsterdam Institute for Global Health & Development

2008 private equity: Investment Fund for Health in Africa, largest

health fund in Africa

2009 largest loans fund for doctors and pharmacies in Africa 2011 medical standards: first accredited quality standards for Africa

2013 mobile health: partnership with Vodafone, M-Pesa and Safaricom

2015 Joep Lange Institute announced, IFHA II and HIF II

Our history

2

2000

2011

2014


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Providing access to key promotive, preventive,curative and rehabilitative health interventionsfor all at an affordable cost, thereby achieving

equity in access.

4

Source: WHO Health report 2010 (1); UNICEF Programme Divison 2012

To achieve universal health coverage, countries needfinancing systems that enable people to use all types of

health services promotion, prevention, treatment andrehabilitation without incurring financial hardship1.

The WHO defines universal health coverage as


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4

Health system: a vicious cycleThe reality is that the health systems of developing countries are stuck in a vicious cycle

Investors, banks & other (public and private) funders Lack of capital in the private health care sector Investments are stifled by high risk & transaction costs; lack of institutions

Lack of regulatory and legal framework

Crowding-out effect on private sector

Demand

Insufficient andnon-organized

client base,

insufficient quality

delivery

Insecure opaque

markets, high risk

& cost,enforceability &

regulatory issues

Supply

Low quality &efficiency

lack of standards

Poor (self)

regulation

Poor business

performance

Lack of access to

capital

Fin

ancing

Delivery

Low Low

Patients Low trust & demand, no prepayment,

catastrophic out-of-pocket expenses

No benchmarking: patients rely on word of

mouth when choosing services

Insurers

Provide

rs

Low

Low

Risk


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Netherlands

0

10

20

30

40

50

60

100 1.000 10.000 100.000

Rich countries have lower out-of-pocket expenses on health than poor countries

In most developing countries, out-of-pocket expenses for health are high (>50%)

70

100

90

Afghanistan

80

% OOP

GDP/Capita

Viet Nam

Thailand

Sri Lanka

China Peru

Norway

Nigeria

CambodiaNicaragua

Guatemala

Costa Rica

Central African Republic Bangladesh

MalaysiaKenya

Japan

India

5

Poor countries have high out-of-pocket costs


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In a decade (1997-2007), the size of IFCs investments in health by region (loans

and equity) out of a total $ 12.8B World Bank Group spending on health.

6

Limited investments

266

10998 95

12

Asia Lat Am Eur Middle E SSAfrica

(million USD)

Improving effectiveness and outcomes for the poor in health, nutrition & population, World Bank 2009


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A tight relationship between GDP income and health expenditure

leaves little room for manoeuver

10

100 1.000 10.000

Log GDP per capita (PPP $)

100

Japan

Costa Rica1.000

10.000

100.000

Peru ChinaThailand

Malaysia

Sri Lanka

NicaraguaNigeria

Netherlands

Viet Nam

Lo

g

Percapita

totalexp

on

health

(PPP

$)

Kenya

India

Guatemala

Germany

7


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The total amount of money in the system must go up

Shift from OOP to pre-paid schemes and achieve reduction of catastrophic out of

pocket expenditure (leveling out)

Increase of investments in health care (private and public)

Public sector should focus on alleviating bad or unknown risks Supply: decrease risk, increase access and quality, enforce investments

Increase risk capital & risk equalization funds to promote investments

Guarantees for cases without collateral or credit history

Introduce and enforce stepwise quality improvement support programs

Reduce reputational risks for financers

Demand: convert OOP in insurance e.g. risk pools

Avoid crowding out by enforcing private funding

Invest in reducing insurance illiteracy and enforcing financial inclusion

Invest in predictive actuarial models in no-data, high risk environments8

The main challenge: how to increase resources for health


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Delivery

F

inancing Higher

Higher

Higher HigherTrust

Demand Supply

Patient

PharmAccess approach: from vicious to virtuous cycleCreate an upward spiral of trust, capital investments, prepayments, access to finance forclinics and improved quality and availability of health services

Insurance /

Risk Pooling

Loans for

providers

Equity

investments

Quality

standardsTrust

Quality

standardsMobile

health

wallet

Research and advocacy across initiatives


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Our approach: summary of activities

10

Quality program: better quality for patients and professionals. Reduces risks for patients,

investors and governments

Loans for clinics: crowd in investments for quality

Health insurance & savings: our health plans reduce out-of-pocket expenses and create

access to affordable quality care for low-income people

mHealth: technological innovation to reduce costs, reach the poor, achieve scale

Access to treatment: strong and scalable next generation access to treatment initiatives

Research and advocacy: advocate for change based on rigorous impact research, and

provide technical assistance to governments and other health systems stakeholders

Leverage public and private funds to lower risks, raise trust, and increase the total amount of

money in health systems. By developing sustainable, scalable healthcare financing and deliverymodels to stimulate both the demand and supply side.


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Formal collaboration with PharmAccess

Group (Netherlands), JCI (USA) and COHSASA

(South Africa)

SafeCare standards tailor-made for resource-

poor settings, ISQua recognized

Stepwise improvement allows for bench-

marking and transparency of quality of care

provision; reward improvements with

certificates

Build local capacity

Covers complete spectrum of healthcare

delivery

Quality Improvement Program SafeCare (1)

The SafeCare standards and methodology

were designed as a delivery model for

institutional healthcare quality assurance

Government: Regulation, enforcement

and measurement

Financial institutes: Medical and financial

risk reduction

Providers: self-regulation of private sector

Patients: Creates trust


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Results

total of 1,681 facilities treating 1.6m

patients every month

76% of facilities show an increase in

assessment scores

54% of clinics show significant increase

(>10 points out of 100) within 2 years

Trained 500 local assessors of partnerorganizations

Trained over 5,000 health professionals

in quality and business planning

Institutionalization of quality

Private provider networks (e.g. K-MET,

PSKenya) have incorporated Safecare

methodology in their quality assurance

programs.

The SafeCare standards have been adopted

as national framework for quality assurance

in Kenya (NHIF) and Tanzania (MOH&SW).

Strategic partnerships with thegovernment of Nigeria and Ghanaian

National Health Insurance Authority to

assist in (further) institutionalizing quality

assurance.

Quality Improvement Program SafeCare (2)

12


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Medical: Quality upgrading at clinic level

Medical upgrading & business plan to improve quality and

efficiency and assessment of results (SafeCare)

Financial: Access to risk capital at bank level

Stepwise approach at affordable terms & conditions toenable expansion of services

The two objectives are interlinked and offered through local

partners: capacity building through health network organizations

and local banks

Access to credit program: Medical Credit Fund (1)

13


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22

65

Affordable capital for quality improvement,

provided through local banks. First hybrid healthdebt fund for loans to African doctors

first loans fund focused on health SMEs

winner of G20-SME challenge award

first loss covered by Dutch MoFA and USAID

first funding round USD 28m Banks launching their own healthcare loans

Fund is extended to provide loans up to USD

1M

14

Access to credit program: Medical Credit Fund (2)

ResultRevolvingPrivate

funding

30

Public

funding

13

Leverage

Revolving

3,500 loans to

2000 clinics

Funding structure and expected result

Debt

Equity

Technical Assistance

(grants)Local Banks

Revolvement710loans

1,373business

assessments

97.7%repayment

rate

USD 13,000average loan


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Highlights

Currently 247,465 lives insured

1.5m patient visits since start of the

program

154,115 malaria treatments

62,175 pregnancies covered by health

insurance

Kwara State (Nigeria) 60% of the population earn


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mHealth can transform healthcare financing and delivery

The mobile phone is rapidly changing theeconomic and social fabric of Africa

Africa is poor in hospital beds, but rich inmobile phones

In Kenya, everyone has access to mobilemoney

Mobile money and mHealth can help todirectly target beneficiaries and reach the

most vulnerable groups

mHealth applications can bridge the lastmile, especially in remote areas

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Delivery

F

inancing Higher

Higher

Higher HigherTrust

mHealth - the missing link to connect everyone

Connecting

3. Providers

2. People

1. Savings groups

Connecting payers, providers and people


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P

roblem

Create mobile health payment

infrastructure to allow pooling

of various sources of funds

Improve business case for

healthcare providers to invest

in quality

Health Payment Infrastructure

Establish national system for

quality assessments using

SafeCare standards

Embed quality in the public

system through cooperation

with NHIF & MOH

Invest in quality and business

improvement of private

healthcare providers through

MCF

Build the business case for

private investments in thehealth sector

InvestmentsQuality Standards

1 2 3

Working towards an integral solutionThree intertwined programs


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Activity highlights: mHealth

Mobile Health Research Lab

designing and testing prototypes for new health

innovations in living labs

devising health solutions for scale

operational in Nairobi since June 2013, Nigeria and

Tanzania to follow in 2015

Health Payment Infrastructure

Creating independent and trusted health payment

institute to drastically reduce transaction costs and

increase liquidity for health providers

improve quality through pay-for-performance

The first 1,600 (private) health facilities already

signed up across Kenya

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Partnerships with M-PESA Foundation, Global Fund, Safaricom, Vodafone and

a broad range of local public and private partners


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Documents

Financing and delivery models for quality health care for low-income groups