Presentation delivered by Dr Awad Mataria, Regional Adviser, Health Systems Development at the 62nd Session of the WHO Regional Committee for the Eastern Mediterranean

1. Social Health Insurance for Universal
Health Coverage
Technical Meeting
62nd Session of the WHO Regional Committee
for the Eastern Mediterranean
5-8 OCTOBER 2015, Kuwait

2. Health Financing Systems and Universal
Health Coverage
• In 2005, Member States endorsed a Resolution that
urges countries to develop their health financing
systems to:
- Ensure that all people have access to needed
services without the risk of financial hardship
• In 2015, Heads of States adopted 17 SDGs with Target
3.8 calling on countries to pursue:
– Universal Health Coverage

3. WHR 2010: Three Dimensions of Universal
Health Coverage
3

4. 4
World Health Organization
The Financing Function
“Collection”
“Purchasing”
“Pooling”
Moving towards Universal Health Coverage Requires
Well-Functioning Health Financing Systems

5. Out-of-Pocket Payments Undermine the Performance of
Health Financing Systems
0
10
20
30
40
50
60
70
80
5
Group 3
40–76%
Group 2
24–58%
Group 1
8–20%
Share of OOP in THE by Country Group, 2013

6. 6
GENERAL GOV’T REVENUE
– Financed through budgetary allocation
– Beveridge approach
– Main source of funding in:
• Globally – UK, Australia, Finland, Italy,
Greece, Sweden and others.
• In EMR – G1: GCC “nationals”; G2: Iraq,
Libya; G3: Afghanistan, Pakistan
SOCIAL HEALTH INSURANCE
– Financed through obligatory payroll taxes
– Bismarck approach
– Main source of funding in:
• Globally – Germany, Japan, France, South
Korea, Turkey and others.
• In EMR – G2: I.R. of Iran, Tunisia, Morocco;
G3: Djibouti
OTHER ARRANGEMENTS
– Private Health Insurance – voluntary/for-profit
– Community-Based Health Insurance – voluntary/not-
for-profit
– Medical Saving Accounts – obligatory with no pooling
– Others
Prepayments Options for Countries to Consider

7. 7
General Government Revenue
Strengths
– Pools risks for whole population
– Relies on many different revenue
sources – taxes, natural
resources, others
– Single centralized governance
system with potential for
administrative efficiency and cost
control
Limitations
– Variations in funding and
budgetary allocations due to
changing gov’t priorities
– Often disproportionately benefits
the better off
– Potentially inefficient due to
complex public sector rules and
procedures

8. 8
Social Health Insurance
Strengths
– Mandatory contributions based on
ability-to-pay
– Perceived as a ‘benefit’ tax with
more ‘willingness to pay’
– Protects health financing from
gov’t annual budgetary process
– Additional health revenue source
Limitations
– Potential to exclude the poor and
vulnerable unless subsidized by
gov’t
– Administrative cost can be high if
fragmented
– Benefit packages do not often cover
for promotive/preventive care
– Potential negative impact on
employment because of increased
cost of production

9. 9
GENERAL GOV’T REVENUE
– Financed through budgetary allocation
– Beveridge approach
– Main source of funding in:
• Globally – UK, Australia, Finland, Italy,
Greece, Sweden and others.
• In EMR – G1: GCC “nationals”; G2: Iraq,
Libya; G3: Afghanistan, Pakistan
SOCIAL HEALTH INSURANCE
– Financed through obligatory payroll taxes
– Bismarck approach
– Main source of funding in:
• Globally – Germany, Japan, France, South
Korea, Turkey and others.
• In EMR – G2: I.R. of Iran, Tunisia, Morocco;
G3: Djibouti
OTHER ARRANGEMENTS
– Private Health Insurance – voluntary/for-profit
– Community-Based Health Insurance – voluntary/not-
for-profit
– Medical Saving Accounts – obligatory with no pooling
– Others
Prepayments Options for Countries to Consider
MIXED OPTION

10. Social Health Insurance Evolution (“SHI for UHC”)
• Historically, SHI covered formal sector (primarily public but
also private) through obligatory payroll taxes
• Today, SHI evolved into a prepayment arrangement that
covers formal and informal sectors and is financed by a
mix of obligatory contributions and government
budgetary allocations
• Why?
– In low- and middle-income countries: large informal sector
(poor and non-poor) and vulnerable populations, unemployment
– In high-income countries: aging populations, “unemployment”

11. 11
“SHI for UHC” in EMR
Scheme 1 Scheme 4 Scheme 3 Scheme 4 Pop (%)
EGY HIO (52%) 52%
IRN
IHIO – 4
Funds
(60%)
SSO – 2
Funds (33%)
AFMSIO
(3.5%)
Others (3.5%) 100%
JOR CIP (41.2%) RMS (27.2%) JUHs (1.3%)
Other
prepayment
(17.5%)
87.5%
MOR
CNOPS
(9.1%)
CNSS (24.9%) RAMED (28%)
Other
prepayment
(4-5%)
66-67%
SUD
NHIF
(28.7%)
Police and
Military
(5.6%)
Other
prepayment
(0.6%)
34.9%

12. “SHI for UHC”
Characterized by:
• Increased Social Solidarity
• (Quasi-) Independent Fund
with Autonomy
• Entitlements because of your
citizenship and not because
of your job
• Split between Financing and
Provision
12
Driving:
• Equity and Fairness
• Strategic Purchasing and
Enhanced Efficiency
• Protected Fund for Health
• Financial Sustainability
• Empowerment of the insured

13. • Covering the near poor and non-poor informal sector
– Need to identify options and pursue their implementation
• Limiting Fragmentation
– Need to structurally/functionally merge HIOs and Schemes
within HIOs
• Ensuring Autonomy and Accountability
– Need to enact necessary legislations and enforce the
regulations
• Investing in Information Technology
– Need to develop population databases and HMIS for purchasing
• Framing the Role of Private Sector
– Need to identify who is covering what and from which provider
Key Policy Issues in Designing “SHI for UHC” in EMR

14. Implementing “SHI for UHC”
• Governance – enact adequate laws and other legal provisions
• Membership Management – bring all population groups within the
fold of SHI
• Fund Management – determine needed fund and set contributions
to ensure sustainability
• Benefit Design – define benefit package and identify who pays for
what
• Provider Management – accredit providers to ensure quality, and
contract wit them using adequate payment mechanisms
• Information Management – establish HMIS, organize provider
reporting and institutionalize monitoring

15. Thank You!