Global Health Conference

The widening  gap  in equity  of  pluralistic health systems in low income and middle income countries in Asia: emerging issues in unregulated health systems.

Rohan
Jayasuriya

There is  wide recognition that health systems in low income and middle income countries have substantial constraints  and that efforts to strengthen them are failing. Evidence shows that  in  countries with pluralistic ( ie mixed)  systems there is a  widening gap  in universal access  to primary care and  a disproportionate financial burden on the poor.

Historically many countries in Asia took the path to build publicly funded national health  systems with a focus  to cater for episodic care of acute disease. These investments in secondary and tertiary facilities are now a costly burden in infrastructure and  specialised  staff. Most countries now face the heaviest burden of disease from chronic disease.   

Private health care has  over the years lead to  a distortion of demand  and health seeking behaviour. Countries face policy issues of an unregulated private sector and dual practice of public sector staff. A comparative analysis of selected case studies from Asian countries will be used to illustrate the underlying factors that contributed  to this situation and to analyse reform strategies , taken by design  and default  to respond to the emerging crisis.

Strengthening public health systems in health sector reform

Vivian Lin

Following a burgeoning of global health funding and orientation towards vertical programming (eg via MDGs, Global Fund and other PPPs), attention has shifted more recently to health system strengthening, as a pre-requisite for successful delivery of program to achieve health outcomes.   The call for renewal of primary health care has become more focused on universal coverage, as health sector reforms sweep across both developed and developing nations. 

The emphasis in health sector reform has been on financing of personal health services, and to a lesser extent the organisation of healthcare and the development of health workforce for personal health care.  Despite studies conducted on core public health functions, there has been limited attention on health promotion, disease prevention, and health promotion, ie activities which are at the core of improving population health outcomes.  Where essential public health services have been incorporated into health system reforms, they have also focused largely on personal preventive services. 

The basic building blocks of public health systems – workforce, financing, information, leadership, organisation – have not necessarily been considered as a core component of health reforms, although the strengthening of public health systems is also needed.  This presentation will review some experiences with improved financing for public health and approaches to strengthen public health systems, and raise issues about what might a public health system strengthening agenda entail. 

Making health systems more accountable for the quality of their health care ,

Judith Healy

Many governments are strengthening their governance in order to become better ‘stewards’ of their health systems. According to the World Health Organisation, this involves three key tasks: setting priorities for improving the health of their populations, assessing progress towards these goals, and ensuring that the relevant actors are held to account. Governments with well-established health care systems are passing legislation and establishing regulatory agencies that require health care organisations and professionals to be more accountable for their performance to the state and to the public. 

These new national meta-regulators are experimenting with strategies that include persuasion, standard-setting, financial incentives and enforcement. The traditional strategy of leaving health care regulation solely to the doctors is no longer acceptable. While poorer countries understandably are preoccupied with funding, they should also consider ways to strengthen their regulation of health care quality in order to make better use of scarce resources and to ensure better health care for their populations. 

Challenges in Universal Health Coverage :

Can Indonesia improve socio-economic and geographic equity together?

Laksono Trisnantoro

In Indonesia the new law on social security agency which targets universal coverage  will be effective  in 2014. While the main objective is to improve health equity it will pose various challenges to access for health services funded by the social security agency with a real possibility of worsening geographic inequity. The presentation will provide historical facts which have influenced health equity in Indonesia and discuss a possible dilemma in reducing economic and geographical inequity at present and in the future. As  a direct response  to the economic crisis  in late 1990’s, financial protection for health care for the poor was set nationally in 1999. 

The protection policy aimed to reduce out of pocket spending by increasing central government funding targeting the poor. A steady growth of central government funding for health social security resulted in a relatively low incidence of catastrophic out of pocket health expenditure, which has declined over time. The financial protection program reduced financial barriers to access for poor households for both hospital and non-hospital services. However, alongside these positive impacts, the regional inequalities in access to services have not improved over time. 

There is regional inequity due to shortages in inputs such as health facilities, medical specialist and trained nurses. Historical facts will be used to explain this situation.  Indonesia has taken the route of market –based economies  and is has not been a welfare state since the colonial era.  Hospitals and health service providers are distributed based on market demands and cluster in the cities and regions with good economic development. Therefore, the new Law faces a difficult challenge in terms of geographic inequity. There is a possibility that the improvement of socio-economic equity may worsen the geographic inequity in Indonesia.