Sustainable Universal Health Coveragein the context of population ageing
A New Research Agenda

Sarah L Barber
Director, World Health Organization Kobe Center

World Health Organization Kobe Center (WKC)

WHO Kobe Centre and its role
- Creation more evidence forachieving UHC Vision:“Innovations for sustainable universal health coverage”

STRATEGI C OBJECTI VE 1:• Support research and evidence to support healthsystem s change, in light of population ageing
STRATEGI C OBJECTI VE 2:• Stim ulate social, technological and system s innovations

World Health Organization Kobe Center (WKC)

Overview• Why population ageing is an important issue forthe world• Health care as a human right: implications forthe design of UHC• Policy issues in moving towards progressive
realization of UHC in light of population ageing

World Health Organization Kobe Center (WKC)

Ageing: most challenge facing health systemof the future (UNDESA 2015))• Between 2015 and2050: share of >60
will increase from
12% to 22% of thepopulation globally• By 2050, 80% of older
people will be living inlow- and middleincome countries,
mostly in Asia.
Sources: WHO Ageing and HealthFactsheet #404 Sept 2015;
UNDESA World Population Ageing
Report 2015.
World Health Organization Kobe Center (WKC)

Change is happening quickly: Increases in LE of
4.1 years in WPR, 5.5 years in SEAR (2000-2015)

Source: Colin Matters, Somnath Chatterji, forthcoming 2017
World Health Organization Kobe Center (WKC)

Population 60 years or older:
Number and share of total population, 2050

Sources: UNDESA database 2017
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Universal health coverage under SDGs:
renewing existing commitments

Universal Declaration of Human Rights, 1948,
and embedded in national constitutions topromote social cohesion:
Everyone has the right to a standard of living adequate for thehealth and well-being of himself and of his family, including food,clothing, housing and medical care and necessary social services,and the right to security in the event of unemployment, sickness,disability, widowhood, old age or other lack of livelihood in
circumstances beyond his control
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Health as a human right:
implications for design of UHC• Reflects the values of equity, fairness and social
solidarity.
• Health care is not a commodity, employmentperk or privilege, but it is a right for all.
• No single model of UHC – successful programsvary and the starting point is the country
context.
• No country has fully “achieved” all UHC
objectives, but many have embarked on an
ongoing process of progressive realization.
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Progressive realization of UHC
Relevant to all countries because similar problems exist– Rapidly increasing health care costs– Lack of protection from catastrophic health carepayments– Variations in technical quality– Services not responsive to people’s needs orexpectations– Lack of access to cost-effective health care
• poverty, lack of insurance coverage,
geography/rural or remotes are, age, sex, ordiscrimination, lack of incentives for the provisionof essential cost-effective proceduresWorld Health Organization Kobe Center (WKC)

(Three) practical questions about moving
towards “sustainable UHC”
• Are there sufficient resources?
• Are the service delivery models appropriate?
• What are the governance implications?
…And how population ageing affects policy responses

World Health Organization Kobe Center (WKC)

Will people be healthy as they age?
Longer LE without
improvements inhealth status may
increase demand
for services over alonger lifetime –resulting in higher
overall healthexpenditures andlower quality of life.
Healthy life expectancy at birth (years) and probability ofpremature death from any of cardiovascular disease, cancer, diabetes
or chronic respiratory disease between age 30 and exact age 70, bycountry, 2015 (WHO 2017)
World Health Organization Kobe Center (WKC)

400

400

1965

350

300

300

age adjusted mortality ( /100,000)

350

Males

250

250

200

200

150

150

100

100

50

5000year

StrokeHeart diseaseTuberculosis
Pneumonia, Bronchitis
Cancer1965

year

Changes in age adjusted mortality rate
World Health Organization -Kobe Center (WKC)

Females

Source: Slide from original by Dr Nobuo Yoshiike, from WHO
NCD conference, Beijing China

Power of prevention: Health improvements are
possible and change can be fast: strokemortality reduction in Japan

Are there sufficient resources?

How much will the government pay for which populations
and which services?

World Health Organization Kobe Center (WKC)

Implications: health as a human right• Systems in place that cover the entire
population• Mandatory or automatic entitlement throughpublic funding (mandatory wage-basedcontributions or general tax revenues)• Mechanisms to fund coverage for people
unable to contributeWorld Health Organization Kobe Center (WKC)A core challenge: settings with a small formal sector(Kutzin 2017)
Countries with large share ofrural and informallyemployed tend to sufferfrom poor tax collection
Implications for healthspending:–More private; more out-ofpocket; more regressive

2014 data

Country
incomegroup

Total
OOP as %governmentof total
spending as
health% GDP
spendingLow

26%

40%

Lowermid30%

43%

Uppermid36%

31%

High42%22%

Source: WHO Global Health Expenditure
Database, countries w/ population > 600,000
World Health Organization Kobe Center (WKC)

Challenges (Kutzin 2017)
Small formal labor force– Major challenge to mobilize wage-based contributions– Given this, the main domestic source of public funding
must be general budget revenues (mainly indirect taxes)– Requires strong engagement with Finance ministries onallocations from public budgets
Larger share of formally employed– Major challenge is changing age composition, reducing
share of economically active population in total– Given this, countries need to consider (further)diversification of public funding sources– Requires strong engagement with Finance ministries onallocations from public budgets
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What is the contribution of ageing to healthcare spending?

Per capita health spending by age group asshare of per capita GDP
Source: OECD 2016 health statistics

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17The service delivery model matters:
Spending on dementia by delivery setting, Korea,
Germany, and the Netherlands

Source: OECD Health Statistics Database, in Spending by Disease,Age, and Gender April 2016
World Health Organization Kobe Center (WKC)

Key drivers of cost escalation (and quality)
globallya) Reliance on hospital-based care for commonconditions, which is more costly and inefficient incomparison with primary care, and may not respond topatient needs.
b) Fee for service payments to health care providers andhospitals that reward volume rather than healthoutcomes, quality of care, and quality of life.
c) Introduction of new technologies, medicines,
diagnostics - without sufficient knowledge about
whether they are better than what is currently used.

World Health Organization Kobe Center (WKC)

WHO PHC service delivery model:
PHC, integration, and continuity
With population ageingcomes stronger
emphasis on quality oflife, functional ability,and social interaction.
Reducing mortality andprolonging life is notalways the appropriate
goal.
During the last years oflife, health needs areoften interlinked withsocial needs.
W orld Health Report 2008

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20

Japan’s integrated community care modelWorld Health Organization Kobe Center (WKC)

Optimize human resources for healthy ageing“Right sizing” the health workforce•Care coordinator•Allied health workers vs specialized support
Empowering people, families and communities•Chronic care largely relies on patients: informationand innovations to enable millions of people tobecome active and involved in self-management.

W orld Health Report 2008

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22

Governing for health and health governing
Source: WHO EURO, 2014
Governance forhealth: investing inhealth as anintegral part ofhealth andeconomicdevelopment;
working acrosssectors in creating
environments thatencourage
individuals
to make healthychoices
World Health Organization Kobe Center (WKC)Healthgovernance:increasing
capacities across awide range oforganizations,communities andindividuals so thatthey canparticipate inhealth decisionmaking towards
better health andsocial welfare.

Maximizing innovations and technologies:
leapfrog progress to UHC
Delivering better quality at lower cost•i.e., electronic medical records, establishing a medical homeand care plans, payment reforms.
Extending the reach of the health system•Telemedicine, reminders for medication adherence
Empowering individuals, families and communities•Apps to promote self management, sensor technology tomonitor falls, providing support to housework and cooking

World Health Organization Kobe Center (WKC)

Conclusions• Early intervention is critical. Population ageing is occurring much
faster than in the past. Risk factor prevention and NCD
management and control can promote healthy ageing.
• More public funding is important – but need to consider funding
in the context of the service delivery models that promoteefficiency.
• Health systems need to adapt. Greater numbers of older person
increases demand, and require integrated, coordinated care withthe goal of better quality of life.
• Governance for health involves many stakeholders, to mobilize
all resources towards better health.
• Innovations can leapfrog progress in achieving UHC: improving
efficiency, empowering people, and extending the reach of thehealth system.
World Health Organization Kobe Center (WKC)

Thank you!

World Health Organization Kobe Center (WKC)