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Should a mix of financing mechanisms be sought, synergies might be created to achieve redistributive effects and address disadvantages associated with private expenditure.
Administrative and governance linkages between the various schemes and systems can have the potential to enhance efficiency by sharing of management functions, mutual
registration support, and further coordination regarding the collection of contributionspremiums, auditing and control, contracting of providers and information
processing.
Revenues that have been collected for health protection purposes should not be incorporated into general government budgets, but instead be accumulated as earmarked
contributions in individual funds. This ensures that contributions are used solely for health protection coverage and access to the defined benefits.
Fiscal space and additional funds needed for extending health protection might be created and generated by increasing the efficiency of resource utilization, strengthening
institutional effectiveness and efficiency, or enforcement, among others Key aspect 4.5.
Generally, countries should be in a position to use national resources to finance health protection. However, if national resources are insufficient to implement the basic
guarantees incorporated in social protection floors, countries may seek international cooperation and support complementary to their own efforts.
4.2.3. Designing and costing essential health-care packages EHCPs
Designing EHCPs The design of EHCPs cannot be identical for each country, given the differences in
demographic, epidemiological, political and socio-economic characteristics. Priorities, needs and capacities define a country’s essential basket of care. Resource-poor countries
might emphasize primary health-care coverage, while other countries add specific treatments for less frequent diseases. In any case, establishing an EHCP is an exercise that
requires careful considerations of priorities, trade-offs, and defining what “essential” services entail for the population. By definition, an EHCP consists of a set of interventions
– usually a combination of in- and out-patient services, including public health and clinical services. It guarantees a basic level of health care for every citizen in a country. However,
it cannot meet all needs of the population, particularly not those with specialized diseases that are not accounted for in the EHCP.
As resources are often scarce, an emphasis on cost-effective interventions is generally found to ensure a maximum health gain with the funds, resources and personnel available.
In the process of determining the composition of the benefit package, trade-offs between
Key aspect 4.5 Options for increasing fiscal space while ensuring sustainability of funding
- Using public resources more efficiently
- Strengthening efficiency in public institutions and service delivery
- Reallocating the government budget
- Putting greater efforts into tax and contribution collection and the prevention of non-compliance
- Governing funds more effectively
- Introducing new sources of funding for the national health budget
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cost-containmenteffectiveness and risk protection are unavoidable. In addition to these objectives, reducing the burden of disease – that is, the impact on morbidity and mortality
in a population – is also considered an important objective. It implies that those conditions posing a heavier burden on society could also be given priority Obermann and Scheil-
Adlung, 2013.
Recommended areas and items of health care are referred to in various ILO Conventions and Recommendations, including the Social Security Convention Minimum Standards
No 102, the Medical Care Recommendation, 1944 No. 69 and the Medical Care and Sickness Benefits Convention, 1969 No. 130. Besides curative care, such as general
practitioner care and hospitalization, preventive measures and maternal care should be considered Key aspect 4.6.
Countries may wish to define the areas to be covered as primary health care, in-patient care, prevention and maternity care rather than using an itemized approach. In all cases,
services covered in EHCP should be based on a consensus derived from broad consultations with all decision-makers and others involved in health protection, taking into
account a broad range of perspectives that are considered relevant in addition to the medical perspective. Key aspect 4.7 lists important aspects for consideration when defining
EHCPs.
Key aspect 4.6 Health-care items referred to in ILO Conventions and Recommendations
on social security and medical care
- Curative care
- Preventive care
- Maternal care
- Necessary pharmaceutical supplies on prescription
- Medical rehabilitation, including the supply, maintenance and renewal of prosthetic and orthopaedic
appliances, as prescribed -
Medical aides such as eyeglasses -
Services for convalescents -
Sickness benefit in cash -
General practitioner care -
Specialist care for in-patients and out-patients -
Hospitalization where necessary -
Dental care, as prescribed
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In order to inform the policy dialogue in the decision-making process related to EHCPs, the ILO suggests a whole-system approach that aims to obtain indicative data for costing
the implementation of an EHCP in a given country.
Costing EHCPs In contrast to a bottom-up calculation that provides a costing of services based on a defined
essential health-care package, the approach suggested by the ILO focuses on indicators for staff, medicines and infrastructure as inputs to a health-care system. By doing so, it aims to
provide an initial rapid assessment of the costs of an EHCP at country level. This approach is particularly suggested for countries where relevant data for costing – such as utilization
rates – are limited. For such a top-down indicative costing, the following conceptual model is proposed:
Part 1. Analysis of current macro-level spending patterns. To determine the level of care
that is available three data inputs will be used: staff, infrastructure and medicines. These three inputs are key for the provision of health care. The relevant data can be found in
national health accounts, and it is assumed that they indicate the level of technical efficiency in the present health-care system of a country. The three indicators are defined
as follows:
staff
: the ratio between the total number of health-care staff doctors, nurses, midwives, administrators and others, both self-employed and in government service
in relation to the whole population;
medicines
: the total per capita expenditure on medicines or total pharmaceutical expenditure TPE in a country, regardless of the source of payment and how they
were obtained; and
infrastructure
: the percentage of total health expenditures spend on infrastructure, derived from the national health accounts.
Part 2. Determination of the appropriate level to be achieved . Based on the assumptions
that i the relation of current levels of spending for staff, medicines and infrastructure is an approximation of technical efficiency; and ii that scaling up to some desirable level
would at least provide the resource basis for some level of adequate care, a “deficiency index” can be developed that consists of the relation between current and desirable
Key aspect 4.7 Aspects to be considered when defining EHCPs
- Introducing comprehensive and complementary benefit packages providing for an adequate level of
services and income protection -
Ensuring availability, affordability and acceptability of health care -
Balancing the trade-off between equity and quality in broad consultations with all actors -
Addressing health-related poverty by minimizing OOP, particularly catastrophic health expenditure 40 per cent of a household’s income net of subsistence
- Ensuring adequacy through a focus on patients’ needs regarding quantity, adequacy and quality of
services -
Providing access to primary, secondary and tertiary care through referral systems, including maternity care, preventive care and care in relation to HIVAIDS
- Providing for transport costs
- Providing for financial protection against loss of income due to sickness, through paid sick leave
andor other forms of income support
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spending. To arrive at this level of desirable spending, a peer group of three countries is formed, based on:
GDP; the vulnerability of countries in terms of socio-economic characteristics poverty rates
and extent of informal economy; and geography.
The three aspects in Part 1 combine common experience the tendency of countries to compare themselves with their neighbours with economic and social indicators. Reference
levels for staff will be based on the ILO Staff Deficit Indicator. For medicines the mean per capita expenditure on medicines in the three countries of the group with the best health
indicators using life expectancy LE, under-5 mortality rates U5MR, and maternal mortality rates MMR, adapted to the medicine price level of the analysed country or if
available the cost of an essential benefit package as defined by WHO will be used. For the indicator infrastructure the model does not use any external benchmark, but would
increase the spending for infrastructure on a pro-rata basis derived from the actual identified increase in spending for staff and medicines.
The result would be the calculated per capita health-care expenditure for delivering an EHCP for everyone in a country. All direct private expenditures above an OOP rate of 35
per cent of total health expenditure this is the actual level of OOP in high-vulnerability countries as per the ILO definition would be considered an inadequate level of financial
protection. Thus, such cost would need to be borne from other sources taxes, social health insurance funds, or if necessary international aid. Finally, the gap between the calculated
requirement and the actual funding with an OOP level below 35 per cent would be called the funding gap.
Following the assessment of deficits in coverage and access and the development of a national rights-based plan aiming at closing gaps and designing and costing the EHCP, it is
essential to ensure successful implementation of the planned reforms, taking into account needs for scaling up the health workforce, creating institutional and administrative
efficiency, and enhancing technical capacities.
Further details and examples of calculations for costing an EHCP can be found in specific ILO publications e.g. Obermann and Scheil-Adlung, 2013.
4.2.4. Coordination of policies within and beyond the health sector
In addition to addressing specific issues in health systems and schemes, it is important to coordinate all health financing mechanisms with a view to achieving universal coverage –
for instance by using a coverage map, as mentioned above, and by creating administrative synergies if different systems and schemes are established.
Further, it is important to coordinate with policies beyond the health sector that impact, for example, on equity in access to health care. Such policy coherence and coordination across
the health, economic and social sectors will also stimulate economic growth and is a key condition for sustainable progress. Of particular importance in this context are policies
focusing on:
poverty alleviation; labour market and decent work; and
